Calcified right atrial mass in a woman receiving long-term intravenous phosphate therapy

Successful tricuspid valve repair and right atrial mass excision for calcified thrombus causing severe tricuspid regurgitation and near-occlusion of inferior vena cava

BACKGROUND

Calcified right atrial thrombus is rare and commonly occurs secondary to atrial fibrillation and long-term central venous catheterization which present risk for embolization. Treatment typically involves anticoagulation and antiplatelet therapy but rarely surgical excision can be performed, especially in patients with venous obstruction or concomitant valvular dysfunction.

CASE PRESENTATION

We present the case of a 69 year old symptomatic female with a history of atrial fibrillation and long-term venous catheterization found to have a large calcified right atrial thrombus causing inferior vena cava obstruction and severe tricuspid regurgitation. Patient underwent full median sternotomy with ascending arterial cannulation with superior vena cava and femoral venous cannulation. Intraoperatively, extensive right atrial calcified thrombus was found extending into the inferior vena cava and involving the septal portion of the tricuspid valve annulus causing regurgitation. The calcified thrombus was removed which resolved the inferior vena cava obstruction and the tricuspid valve was repaired by transecting septal leaflet chordae, commissuroplasty, and ring annuloplasty. Postoperative course was uncomplicated and pathology confirmed a calcified right atrial thrombus. At 6 month follow up, the patient was asymptomatic with echocardiogram showing no inferior vena cava stenosis and trivial tricuspid regurgitation.

CONCLUSIONS

Surgical excision of calcified right atrial thrombus is rare and is often indicated for symptomatic patients with extensive involvement causing venous inflow obstruction or valvular dysfunction. Sufficient preoperative imaging and a multi-disciplinary approach are essential for accurate diagnosis to guide targeted treatment. When the tricuspid valve is involved, repair is preferred over replacement in this patient population given their propensity for calcification and thrombus formation which may result in an increased risk of early bioprosthetic valve degeneration or mechanical valve thrombosis.

Surgical retrieval of PICC-related right atrial thrombus in a child with acute lymphoblastic leukemia: a case report

Background

Peripherally inserted central catheters (PICCs) are widely used in cancer patients for administering chemotherapy drugs, antibiotics, and nutrients. PICC-related thrombi are not uncommon and may result in pulmonary embolism and the formation of thrombi in the right atrium. The latter are associated with an increased risk of subsequent morbidity or mortality because of their potential for embolization in the pulmonary vasculature.

Case presentation

A 16-year-old male with acute lymphoblastic leukemia (ALL) was admitted to our hospital after an echocardiographic examination revealed a ring-like structure in the right atrium that was still present after 6 months’ anticoagulation treatment with aspirin. The boy had had a PICC inserted 2 years previously for chemotherapy; the PICC was intact and successfully removed 18 months after insertion when chemotherapy is finished. Subsequent computer tomography and radiography differentiated right atrial ring-shaped mass with a diameter of approximately 15 mm. Cardiac surgery was performed to remove the mass which was found to be a calcified thrombus.

Conclusion

Although this is a rare occurrence, recognition of the possibility of a calcified thrombus may minimize the misdiagnosis of PICC-related thrombus and allow surgical retrieval if the thrombus is sufficiently large.

Right Atrial Calcified Ball Thrombus Mimicking a Myxoma

An 80-year-old woman was admitted to our hospital because of congestive heart failure. Transthoracic echocardiography revealed severe aortic valve stenosis, and a mobile calcified mass was attached to the interatrial septum in the right atrium. We suspected that the mass was cardiac myxoma. We urgently performed aortic valve replacement and resection of the mass. The histological diagnosis of the mass was thrombus, and her post-operative course was uneventful. Although the mechanism of right atrial thrombus formation in our case was unclear, it is important to continue anticoagulation therapy after surgery to avoid recurrence. Furthermore, strict follow-up in this patient is needed.

CT and MRI evaluation of cardiac complications in patients with hematologic diseases: a pictorial review

Cardiac complications with hematologic diseases are not uncommon but it is difficult to diagnose, due to non-specific clinical symptoms. Prompt recognition of these potentially fatal complications by cardiac computed tomography (CT) or cardiac magnetic resonance imaging (MRI) may help to direct clinicians to specific treatments according to causes. Thrombosis is often related to central venous catheter use and is usually located at the catheter tip near the atrial wall. Differentiation of thrombosis from normal structure is possible with CT and, distinction of a thrombus from a tumor is possible on a delayed enhancement MRI with a long inversion time (500-600 ms). Granulocytic sarcoma of the heart is indicated by an infiltrative nature with involvement of whole layers of myocardium on CT and MRI. MRI with T2* mapping is useful in evaluating myocardial iron content in patients with hemochromatosis. Diffuse subendocardial enhancement is typically observed on delayed MRIs in patients with cardiac amyloidosis. T1 mapping is an emerging tool to diagnose amyloidosis. Myocardial abscess can occur due to an immunocompromised status. CT and MRI show loculated lesions with fluid density and concomitant rim-like contrast enhancement. Awareness of CT and MRI findings of cardiac complications of hematologic diseases can be helpful to physicians for clinical decision making and treatment.

Calcified amorphous tumor of the heart with purple digit

A calcified amorphous tumor (CAT) of the right atrium (RA) is an exceedingly rare non-neoplastic cardiac mass. It was initially described in 1997 and only a handful of cases has been published so far. We present a case of tumor in 77-year-old male, in the RA that attached to the rim of the fossa ovalis, with classic pathological and clinical findings. Under cardiopulmonary bypass (CPB) and bicaval and aortic cannulation and cardioplegic arrest, right atrial mass, was resected and septal defect was repaired with a fresh pericardial patch. Pathological exam of the mass revealed CAT. The patient had an uneventful hospitalization and his blue discoloration of finger recovered normally.

Calcified catheter "cast" masquerading as a retained catheter fragment after removal of an implanted venous access device

Calcified catheter "cast" found on radiologic studies after central venous catheter removal is a rare complication that has been reported twice. Both cases were associated with thrombus. In this case report, we present a 15-year-old boy with acute lymphoblastic leukemia who demonstrated on CT scan a radiopacity in his left brachiocephalic vein after removal of an implanted venous access device. This was initially thought to be a retained catheter fragment. Diagnostic studies, including venogram, excluded the presence of a retained catheter fragment. Additional procedures to retrieve a nonexistent catheter fragment were thus avoided. Therefore, a catheter "cast" should be considered as part of the differential diagnosis when calcification is found on an imaging study after removal of an implantable venous access device to prevent an unwarranted surgical exploration.

Recurrent cardiac calcific amorphous tumor: the CAT had a kitten

BACKGROUND

Cardiac calcified amorphous tumors (CATs) represent degenerating intracavitary mural thrombi that can mimic neoplasms and cause symptoms due to embolization or obstruction. Surgical excision is generally curative. Postoperative recurrences have not been previously reported.

METHODS

Medical, surgical, and pathological records were reviewed in a patient who had undergone removal of a recurrent cardiac CAT.

RESULTS

The patient, now a 23-year-old woman, had undergone excision of the initial right ventricular mass on November 4, 2003, because of recent pulmonary embolization. Extensive clinical evaluation showed no coagulation abnormality. Follow-up postoperative echocardiograms showed incomplete excision and subsequent enlargement. As a result, the recurrent mass was excised on March 14, 2006. Microscopic evaluation showed degenerating and focally calcifying thrombus, without neoplastic features.

CONCLUSION

Cardiac CAT may recur and enlarge following surgical excision. Periodic postoperative follow-up with cardiac imaging studies may be indicated, particularly if there is evidence of incomplete excision.

[Calcification of thrombus associated with central venous catheter: unusual complication]

Thrombosis originating from the tip of central venous catheter is a well known complication. The calcification of such a thrombus is very rare. Until now, only two cases had been described with long-term indwelling central venous catheters used for total parenteral nutrition. We report the first case of a calcified thrombus occurred during a short-term central venous catheterisation. The presumptive mechanism of thrombus calcification is precipitation of calcium salts and its deposition on a pre-existent thrombus. In total parenteral nutrition the mechanism of calcification seems to be multifactorial. Thus, the precipitation of calcium phosphate is increased by the following factors: higher calcium and phosphate concentrations, the use of calcium chloride instead of calcium gluconate, lower pH solutions, slow infusion rate.