Shogo Shimada and Louis Samuels*
Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
Received: 08 September, 2017; Accepted: 20 September, 2017; Published: 21 September, 2017
Louis Samuels MD, Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, 1025 Walnut Street, Suite 607 Philadelphia, PA 19107, Tel: (215) 955-6996 Fax: (215) 955-6010; E-mail:
Shimada S, Samuels L (2017) Right atrial thrombus: A new cause of Paroxysmal complete Heart Block. J Cardiovasc Med Cardiol 4(3): 062-064. 10.17352/2455-2976.000051
© 2017 Shimada S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
We present a patient with a large right atrial (RA) thrombus complicated by paroxysmal complete atrioventricular (AV) block requiring urgent surgery. This is a rare complication of RA thrombi with the potential pathogenesis being direct mechanical insult on the AV node by the thrombus. Surgical thrombectomy led to complete resolution.
Right Atrial (RA) thrombi develop in a variety of clinical situations. Most of them are found incidentally by echocardiography and thus, rarely cause obvious clinical symptoms unless they embolize distally. Herein, we report a unique case of a large, well-organized RA thrombus which caused paroxysmal complete AV block.
A 40 year-old woman with a history of ulcerative colitis with recent flare, diabetes mellitus, and morbid obesity (BMI 47) presented to the emergency department with a syncopal episode. She was tachycardic and hypotensive refractory to intravenous fluid resuscitation. She was also found to have pancytopenia and acute kidney injury. She was started on empiric antibiotics and vasopressor support via a central venous catheter. She was admitted to the medical intensive care unit (MICU) with a presumptive diagnosis of sepsis. Microbiologic cultures were positive for E. coli bacteremia and Clostridium difficile colitis.
In the MICU she developed hypoxic respiratory failure requiring intubation. A non-contrast computed tomography (CT) scan of the abdomen showed colitis with no apparent structural abnormalities around the inferior vena cava (IVC). Duplex ultrasonography of the abdomen and pelvis, however, showed a 4.3 X 2.2 X 2.7 mass at the cavo-atrial junction. Computer Tomography of the chest with contrast was not performed due to renal dysfunction with elevated creatinine. Transthoracic echocardiography (TTE) confirmed the presence of a large, mobile RA mass arising from the uppermost IVC extending into the RA proper. Echocardiographic assessment of the cardiac function was normal, estimation of the pulmonary artery pressures were within normal limits, and there was no significant tricuspid stenosis or regurgitaton. No deep vein thrombosis (DVT) was noted by ultrasonography of the lower extremities. The mass was thought to be a thrombus for which heparin infusion was initiated. Although the sepsis syndrome improved, the clinical course was further complicated by lower GI bleeding necessitating discontinuation of heparin. Repeat TTE showed no change in the RA thrombus and RV function. Furthermore, the patient rhythm demonstrated intermittent conversion from sinus tachycardia (Figure 1A) to paroxysmal complete AV block with simultaneous sinus slowing (Figure 1B). Considering the size and location of the thrombus, it was postulated that the RA thrombus was causing this complication by intermittent mechanical interference with the AV node within the anatomic Triangle of Koch. The decision was made to proceed with urgent surgical thrombectomy.
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