Right atrial mural thrombi: An autopsy study of an under-diagnosed complication at an unusual site

Calcified Right Atrial Thrombus With Near-Systemic Pulmonary Pressures in a Morbidly Obese Patient: A Clinical Conundrum

Intracardiac masses are not uncommon, but a calcified right atrial thrombus (CRAT) is an exceedingly rare entity and often poses a diagnostic and therapeutic dilemma. We discuss the case of an incidentally noted CcRAT in a 40-year-old man presenting with progressive dyspnea. We further review the literature on the subject, highlighting the need for an individual patient-centred care plan.

Asymptomatic pulmonary thromboembolism due to hemodialisys catheter thrombosis: case series and literature review

Right atrial thrombus is commonly associated to catheters. Catheter-related right atrial thrombus (CRAT) in hemodialysis patients frequently presents as pulmonary embolism. Although CRAT is sometimes asymptomatic, even in these cases it is associated with worse prognosis. The management strategy for CRAT is not well established, however, along with catheter removal, anticoagulation, thrombolysis, and surgical thrombectomy may be performed. Suspicion of asymptomatic pulmonary embolism associated to CRAT is important in order to perform proper treatment. The authors of this article report two cases of asymptomatic pulmonary thromboembolism due to CRAT in hemodialysis patients and perform a review of the literature.

Internal Jugular Central Venous Catheter Tip Migration: Patient and Procedural Factors

Background: The ideal central venous catheter (CVC) tip position placement is controversial, and CVCs do not remain in a fixed position after placement. This study evaluates both patient and procedural factors which may influence CVC tip migration and subsequent catheter dysfunction. Materials and Methods: This study evaluates CVC placements at a single institution. Patient age, gender, body mass index (BMI), catheter laterality, CVC type and indication for central venous access were recorded. Catheter tip location relative to the carina was measured at time of placement and removal utilizing supine fluoroscopic imaging. Patients’ electronic medical records were reviewed for evidence of catheter dysfunction. Statistical analysis was performed utilizing odds ratios and two tailed Student’s t-test. Results: 177 patients were included (101 female; mean age 55; mean BMI 29.2). Catheter types included 122 ports, 50 tunneled large bore central venous catheters (≥9 French), and 5 tunneled small bore central venous catheters (<9 French). 127 were right sided catheters, and 50 were left sided. Left sided CVCs had a mean cranial tip migration of 3.2 cm (standard deviation ±2.9 cm) compared to 0.8 cm (standard deviation ±1.9 cm) for right sided catheters (p = 0.000008). Catheters that migrated cranially by >2 cm had more than 7× greater risk of dysfunction compared to catheters that migrated ≤2 cm (odds ratio of 7.2; p = 0.0001). Left sided CVCs were significantly more likely to have >2 cm of cranial migration (odds ratio 6.9, 95% CI 3.4−14.2, p < 0.0001) and had a higher rate of dysfunction, likely due to this cranial migration (32% vs. 4.7%; p = 0.00001). Gender and BMI were not found to be associated with catheter dysfunction or an increased odds ratio of >2 cm cranial migration. Conclusions: Left-sided CVCs migrate an average of 2.4 cm cranially more than right-sided catheters. Additionally, when migration occurs, left-sided catheters are more likely to be dysfunctional. These suggest that lower initial placement may be beneficial in left-sided catheters.

Incidental Finding of a Large Right Atrial Thrombus in a Patient With Cerebral Lymphoma

Right atrial (RA) masses are rare, challenging to diagnose, and potentially life-threatening with high mortality if untreated. We present a patient presenting with diffuse large B-cell lymphoma in the brain that was incidentally found to have a large RA mass. For a better definition of the RA mass, extensive workup using multimodality imaging including chest computed tomography, transthoracic echocardiography, transesophageal echocardiography, cardiac magnetic resonance imaging, and left heart catheterization was warranted. The imaging demonstrated a large RA mass extending through the tricuspid valve into the right ventricle and superior and inferior vena cava without a mobile component. The mass was then successfully resected, and further histology examination was performed to rule out lymphoma and rare subtypes of diffuse large B-cell lymphoma. The comprehensive workup proved the RA mass to be a calcified thrombus rather than a direct metastatic spread of lymphoma.

Listeria myopericarditis associated with right atrial mural thrombus: a case report

Background 

Pericarditis is a common cardiology presentation, most often due to a viral or idiopathic cause. Listeria as a cause of pericarditis is rare. Listeria is an infection that is readily treatable with antibiotics following accurate identification. Without adequate treatment, Listeria infection has a high mortality rate.

Case summary 

In this case, a fit and well 59-year-old man complained of headaches and fever to the emergency department (ED). He was provisionally diagnosed with giant cell arteritis (GCA) and commenced on management pathways for GCA. He represented to the ED with chest pain and electrocardiogram (ECG) changes suggestive of a clinical presentation of pericarditis. He received treatment for idiopathic pericarditis with no clinical resolution. Cardiac magnetic resonance imaging (MRI) showed myopericardial inflammation associated with a right atrial mural thrombus. After 2 weeks of poor treatment response, peripheral blood cultures grew Listeria monocytogenes and the patient responded well to antibiotic treatment. Repeat cardiac MRI after an extended course of antibiotics showed resolution of MRI signs.

Discussion 

This is a case of Listeria myopericarditis. Physicians should consider rarer causes of myopericarditis in treatment resistance cases. Cardiac MRI has utility in atypical or treatment resistant patients to assess myopericardial inflammation and response to treatment.

Removal of Peritnoeo-venous-atrial shunt thrombus without cardiopulmonary bypass

Thrombus formation is not uncommon in longstanding intracardiac catheters, but formation of a thrombus at the tip of a Peritnoeo-venous-atrial shunt, causing obstruction of the tricuspid valve, is a rare complication and frequently unrecognized. A large intracardiac thrombus causing valve obstruction requires surgical removal with the support of cardiopulmonary bypass which is associated with significant morbidity. We successfully removed a thrombus attached to the tip of peritoneovenous shunt without cardiopulmonary bypass in a 25-year-old man.

Both-sided native valve infective endocarditis in a drug addict with incidental pneumoconiosis

Involvement of both right and left heart chambers with infective endocarditis is extremely rare. In this case report, we aimed to present a rare case of Infective endocarditis (IE) in an intravenous & inhalational drug misuse involving both cardiac chambers with incidental pneumoconiosis.

Cytomegalovirus and Aspergillus spp. coinfection in organ transplantation: a case report and review of the literature

With the advent of potent immunosuppressive options, acute rejection episodes have decreased at the expense of increased incidence of opportunistic infections in solid organ recipients. In the absence of any preventive therapy, 30–75 % of transplant recipients develop cytomegalovirus (CMV) infection. Candida spp. and Aspergillus spp. account for more than 80 % of invasive fungal infections in solid organ recipients. This co-occurrence of two commonly seen opportunistic infections may end up in fatality. Here, we present a case of concomitant Aspergillus spp. and CMV infection and discuss the relevant literature. A 54-year-old male patient presented with fever, shortness of breath, and chest pain on the 9th posttransplant week after renal transplantation. CMV-DNA by polymerase chain reaction (PCR) was 1,680,000 copies/ml, thus, valganciclovir dose was increased. There were inspiratory crackles at both lung bases, and chest computed tomography (CT) revealed multiple fungal balls throughout the right lung. Galactomannan antigen was positive, and voriconazole and other antimicrobials were subsequently added to the treatment. At the end of the therapy, on control CT, pneumonic consolidation had disappeared, sputum cultures didn’t show Aspergillus spp., and CMV-DNA reduced to 700 copies/ml. The patient showed a favorable clinical response to combined treatment; fever, dyspnea, and pleuritic chest pain disappeared. Both CMV disease and aspergillosis may present as pulmonary disease; thus, the characterization of one may not preclude the search for the other and the timely initiation of treatment is of paramount importance for good outcomes.

Surgical treatment for pulmonary aspergilloma: a 35-year experience in the Chinese population

The surgical treatment of pulmonary aspergilloma is challenging and controversial. This study was designed to evaluate the clinical profile, indications and surgical outcomes of pulmonary aspergilloma operated on in our institute. A total of 256 patients with pulmonary aspergilloma underwent surgical treatment from 1975 to 2010. The patients were divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160). The principal underlying lung disease was tuberculosis (71.1%). The surgical procedures consisted of 212 lobectomies in both groups; eight cavernoplasties, 10 bilobectomies, 16 pneumonectomies and six thoracoplasties in Group B; four segmentectomies and six wedge resections in Group A. Postoperative complications occurred in 40 patients (15.6%). The major complications were residual pleural space (3.9%), prolonged air leak (3.1%), bronchopleural fistula (1.6%), excessive bleeding (1.6%), respiratory insufficiency (1.9%) and empyema (1.2%). No intraoperative deaths occurred. The overall mortality within 30 days post-operation was 1.2%, occurring only in Group B. There was no statistically significant difference in the postoperative morbidity between Groups A and B (P = 0.27). With the good selection of patients, meticulous surgical techniques and good postoperative management, aggressive surgical treatment with anti-fungal therapy for pulmonary aspergilloma is safe and effective, and can achieve favourable outcomes.