Cardiac masses are relatively rare, but still form an important part of cardiology practice [1]. Their accurate diagnosis can be challenging, but it is crucial to determine the appropriate treatment.
A 52-year-old female was admitted to the Cardiology Department for further evaluation of a mass in the right atrium (RA) incidentally detected during a transthoracic echocardiography (Figure 1A). In 2020, the patient had suffered a subarachnoid hemorrhage resulting in hydrocephalus. She was treated by embolization of the ruptured aneurysm in the left vertebral artery and placement of a ventriculoperitoneal shunt, which allows the flow of cerebrospinal fluid from the cerebral ventricular system to the peritoneal space [2]. Due to recurrent peritonitis, the shunt was repositioned to the RA.
Transesophageal echocardiography (TEE) confirmed a 9 × 18 mm pedunculated mass originating from the wall of the RA (Figure 1B). TEE also showed the tip of the ventriculoatrial shunt pointing toward the RA wall (Supplementary material, Video S1). A cardiac myxoma was initially suspected, which although rare can occur in this location [3]. The patient was referred for cardiac magnetic resonance (CMR) imaging to characterize the morphology and extent of the mass. CMR showed an additional irregular floating structure attached to the wall of the right atrium, with low signal intensity in T1- and T2-weighted images, non-enhancing on early gadolinium enhancement sequences with long inversion time (600 ms), which indicated thrombus (Figure 1C; Supplementary material, Video S3, S4, Figure S1). Oral anticoagulant (OAC) treatment with vitamin K antagonist was initiated, and the patient was consulted by the Heart Team, which qualified her for catheter-directed mechanical aspiration thrombectomy via the AngioVac system (Angio Dynamics, Latham, NY, US) in the Department of Cardiac Surgery and Transplantology. A short 18 Fr cannula (Edwards, Irvine, CA, US) was inserted through the left common femoral vein for blood reinfusion from the circuit. The AngioVac 0-180 system was inserted into the RA through a right CVF approach using the GORE Flex 26 Fr sheet. In the perioperative period, OAC was switched to unfractionated heparin at a dose of 100 units/kg. The device tip was positioned near the mass with the control in TEE and fluoroscopy (Figure 1D). Extracorporeal perfusion was started with a centrifugal pump (RotaFlow, Getinge, Germany) with an initial speed of 500 rotations per minute (rpm), then increased to over 3000 rpm. Successful mass aspiration was subsequently achieved and confirmed in TEE (Supplementary material, Video S4). After blood reinfusion, the mass was observed in the filter chamber (Figure 1F).
Postoperative histopathological examination confirmed the formation of a thrombus. The patient was discharged on the third day after the procedure, and referred to the medical center where the shunt had been inserted, to consider its repositioning. Until then, it was decided to continue OAC treatment with vitamin K antagonist. There were no adverse events during the 1-month follow-up.
Intracardiac masses may occasionally be thromboses related to the use of central venous catheters. Advanced imaging techniques, such as TEE and CMR, are essential for their diagnosis. In recent years, the AngioVac system has emerged as a promising and safe treatment for the endovascular removal of pathological masses located on the right side of the heart and large vessels [4, 5].
Supplementary material
Supplementary material is available at https://journals.viamedica.pl/polish_heart_journal.
Article information
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