Interact CardioVasc Thorac Surg 2008;7:667-669. doi:10.1510/icvts.2008.179093
© 2008 European Association of Cardio-Thoracic Surgery
Negative results - Cardiac general |
Mobile biatrial thrombus in a patient with mitral stenosis under heparin infusion
Kutay Tasdemira,
Bahadir Sarlib,
Mehmet G. Kayab,* and
Ozgur Gunebakmazb
a Department of Cardiovascular Surgery, Erciyes University School of Medicine, 38039 Kayseri, Turkey
b Department of Cardiology, Erciyes University School of Medicine, 38039 Kayseri, Turkey
Received 3 March 2008;
received in revised form 9 April 2008;
accepted 10 April 2008
*Corresponding author. Tel.: +90 352 3374937/27792; fax: +90 352 4376198.
E-mail address: drmgkaya{at}yahoo.com (M.G. Kaya).
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Abstract
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A 58-year-old female patient with complaints of sudden presenting pain and pallor on her left foot was referred to our clinic for urgent embolectomy. On her cardiovascular examination there was an apical grade 2/6 systolic murmur and a grade 2/4 diastolic murmur. The presenting electrocardiography revealed atrial fibrillation with rapid ventricular response. She underwent emergent femoro-popliteal embolectomy. Transthoracic echocardiography showed a mobile 1.4x1.7-cm sized left atrial thrombus, mild mitral regurgitation and 9 mmHg mean gradient on mitral valve after embolectomy. Unfractioned (UF) heparin infusion was initiated immediately after surgery. After three days, the control transthoracic echocardiography revealed left atrial thrombus and also a large ‘snake-like’ thrombus waving in right atrium. The patient underwent biatrial thrombectomy and mitral valve replacement. When she became haemodynamically stable, a bilateral lower limb venous Doppler ultrasonographic study was performed. This study indicated a thrombus formation in the deep veins of the left leg. The origin of the right atrial thrombus was probably a snapped piece of thrombus from the calf deep-veins after the initiation of intravenous UF heparin. In summary, we have reported an extremely rare case of biatrial thrombus in a patient under UF heparin infusion.
Key Words: Mitral stenosis; Thrombus; Heparin
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1. Introduction
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Thrombus in both the left and right atrium is a rare clinical entity [1]. However, this clinical situation can cause embolic episodes through systemic and pulmonary circulation and can bring on catastrophic consequences potentially resulting in death. Being aware of such an entity, early diagnosis may prevent significant morbidity and may improve patients' recovery by early management. In the present case we report a biatrial thrombus developed secondary to initiation of i.v. heparin infusion.
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2. Case
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A 58-year-old female patient with complaints of sudden presenting pain and pallor on her left foot was referred to our clinic for emergency embolectomy. She had a history of coronary angiography two months earlier (normal coronary arteries). Her supine arterial blood pressure was 120/70 mmHg, heart rate 75 bpm, and her temperature was 36.7 °C. On physical examination there was a grade 2/4 diastolic murmur and a apical grade 2/6 systolic murmur. The left foot was pulseless. The presenting electrocardiography revealed atrial fibrillation with rapid ventricular response. She underwent urgent femoro-popliteal embolectomy. Histopathological examination of the material removed with the femoro-popliteal embolectomy was compatible with thrombus. After embolectomy, transthoracic echocardiography was performed to detect the origin of the thrombus. Transthoracic echocardiography revealed a mobile 1.4x1.7-cm sized left atrial thrombus, mild mitral regurgitation and 9 mmHg mean gradient on mitral valve (Fig. 1a). Although transoesophageal echocardiography was available, the patient refused transoesophageal echocardiography because of the invasive nature of this procedure. I.v. unfractioned (UF) heparin infusion was initiated immediately after surgery. The aPTT (activated partial thromboplastin time) value was high being 2.5–3.5 times that of normal values. The full blood count, electrolytes, LDL-cholesterol and coagulation profile including factor C, S, factor V Leiden, antithrombin-III and anticardiolipin antibody were normal. In the postoperative period her body temperature sustained under 37 °C. Multiple blood cultures were obtained to exclude infective endocarditis and all were negative. Platelet count was within normal limits (275x103 µ/l) when i.v. heparin infusion was started. During i.v. heparin infusion, when aPTT value was optimal, three days after the first exam control echocardiography was performed to see if the size of the thrombus was reduced. The control echocardiography showed preceding left atrial thrombus and also a large ‘snake-like’ thrombus waving in the right atrium (Fig. 1b).
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Fig. 1. (a) Transthoracic echocardiographic view of mobile 1.4x1.7-cm sized left atrial thrombus. (b) Transthoracic echocardiographic view presenting a mobile thrombus in left atrium and a snake-like waving thrombus in right atrium.
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The patient underwent biatrial thrombectomy and mitral valve replacement. A 22-cm-long block thrombus was removed from the right atrium and inferior vena cava. The intraoperative visual and manual examination of the mitral valve revealed fibrotic leaflets and thickened commissures. The fibrotic mitral valve was excised and replaced with a bileaflet mechanical prosthetic valve. She became haemodynamically stable a few days later and a lower extremity venous Doppler ultrasonographic a study was performed to investigate the deep venous system. Doppler USG study indicated unilateral calf deep-vein thrombosis. Thoracoabdominal computerised tomography, which was performed to exclude any other sources of right atrial thromboembolus, indicated a normal CT-scan without signs of thoracal or abdominal malignancy. The origin of the right atrial thrombus was probably a snapped piece of thrombus from the deep-veins vein after the initiation of i.v. UF heparin (Fig. 2). The postoperative recovery was uneventful. She has thus far remained asymptomatic at 12 months follow-up.
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3. Discussion
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Intracardiac thrombus may develop as a result of variable underlying cardiac disorders. Thrombus in the cardiac chambers is frequently associated with atrial fibrillation, valvular heart disease, hypercoagulable state and acute myocardial infarction [1]. Systolic dysfunction and dilated cardiomyopathy are also predisposing disorders for atrial thrombus generation [2]. Also, vegetations in cardiac chambers and metastatic calcifications of cardiac structures may cause mass images as cardiac thrombus [3]. Obtaining multiple blood cultures and careful echocardiographic examination is essential in differential diagnosis.
Floating right heart thrombus usually migrates from deep veins of the legs and, if diagnosed, it should be managed urgently as it can embolise anytime with mortality of 40% [4]. Surgery is the classical treatment in most of the cases. Other management strategies include fibrinolysis and anticoagulation [5].
Although transoesophageal echocardiography has many advantages, transthoracic echocardiography can also be used as a feasible technique in diagnosing intracardiac thrombus [6].
Biatrial thrombus is a rare clinical event. Clinicians mostly initiate UF heparin as the first step for the treatment of masses considered as thrombus. But heparin – more common with UF heparin than LMWH – also may cause new thrombi in cardiac chambers by inducing heparin-induced thrombocytopoenia (HITT) [7, 8]. HITT is an immune mediated complication of heparin infusion and may proceed with venous and arterial thrombosis. It usually occurs five days after starting heparin and, when suspected, heparin infusion must be stopped [9]. In the absence of HITT, a new developing thrombus in the right cardiac chambers soon after the initiation of UF heparin may be associated with the migration of clot pieces from venous system if the patient has underlying causes for deep venous thrombosis such as orthopaedic surgery, malignancy or prolonged immobility due to any cause. B-mode ultrasonography with colour Doppler imaging can be used to establish lower extremity deep venous thrombus with high sensitivity and specifity, like the existing case [10]. In the present case, since the second episode of thrombosis in the right atrium developed within the first three days of heparin infusion and the post-heparin platelet count was normal, we excluded the diagnosis of HITT.
In summary, we have reported an extremely rare case of biatrial thrombus in a patient under UF heparin infusion. In our opinion, the second episode of the thrombosis might have been a result of the thrombus movement from the deep veins in the legs. In conclusion, we consider that if a patient with suspected or known deep venous thrombosis is commenced on i.v. heparin infusion, close transthoracic echocardiographic evaluation is required in terms of right heart or pulmonary embolus development.
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References
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Abstract
1. Introduction