Biatrial Appendage Thrombi in a Heart Failure Patient With Sinus Rhythm
Detailed Assessment by Real-Time 3-Dimensional Transesophageal Echocardiography
A 38-year-old man was referred to our hospital because of progressive dyspnea on exertion. He was diagnosed as having congestive heart failure. On physical examination, his blood pressure was 118/86 mm Hg, and his heart rate was regular at 80 beats/min. On admission, jugular venous distension was detected, a third heat sound was audible, and auscultation of the lungs revealed bilateral coarse crackles and diminished breath sounds. Peripheral edema was also detected. A chest x-ray film showed a marked cardiac silhouette, with right-sided pleural effusion (Figure 1A). ECG on admission showed sinus rhythm with poor R progression and ST depression in aVF and V6 leads (Figure 1B). A blood test showed elevated plasma brain natriuretic peptide (417.9 pg/mL) and d-dimer (6.7 μg/m) levels. Transthoracic echocardiography revealed normal-sized left and right ventricles and the presence of a small amount of pericardial effusion; the left ventricular ejection fraction was severely decreased. The left and right atria were markedly enlarged (Figure 2). Transesophageal echocardiography (TEE) confirmed the presence of a large mobile thrombus (42×20 mm) in the left atrial appendage. Real-time 3-dimensional TEE provided an en face view of the left atrial appendage, and clearly showed a ball-like thrombus swinging at the orifice of the left atrial appendage (Figure 3, Movies I and II in the online-only Data Supplement). TEE also showed a mural thrombus (40×10 mm) within the dilated right atrial appendage. Using real-time 3-dimensional TEE, we could delineate the extent of the thrombus in the right atrial appendage (Figure 4, Movies III and IV in the online-only Data Supplement). No pulmonary arterial thromboembolism was detected (Figure 5). There were no signs of deep vein thrombosis in the lower extremities during his clinical course. Intravenous heparinization was administered to prevent any thromboembolic occurrence during follow-up. We finally decided to perform surgery because of the highly mobile and large thrombi. Biatrial thrombectomy, pulmonary vein isolation, left atrial appendage closure, and partial excision of the right atrial wall were performed without major complications. Myocardial biopsy showed that the findings were compatible with dilated cardiomyopathy. Microscopic examination of the intra-atrial mass revealed a fibrin-erythrocyte thrombus (Figure 6).
We report a rare case of biatrial mobile thrombus that developed in a patient with heart failure. Right atrial appendage thrombus in sinus rhythm is an uncommon finding, and is typically associated atrial fibrillation (only a few cases have been reported).1,2
Physicians need to recognize that right atrial appendage thrombus can occur in patients without atrial fibrillation, especially in those with right ventricular dysfunction (patients with heart failure). Divitiis et al3 reported that right atrial spontaneous echo contrast is an independent predictor of right appendage thrombosis. Multiplane TEE (eg, midesophageal bicaval view, 90°; view, 150°) is useful for visualizing right atrial appendage thrombus. Real-time 3-dimensional TEE is also useful for visualizing right atrial structures,4 and allows detailed assessment of the extent of right atrial mural thrombus.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.115.018522/-/DC1.
- © 2015 American Heart Association, Inc.