An unusual case is reported of right atrial thrombus associated with cardiogenic offence The role of two-dimensional echocardiography in detection of descendants clots is highlighted.

(Chest 1993; 104:1609-10)

With the availabdity of two-dimensional echocardiography, right atrial thrombus is becoming an incrcasingjy important and more recognized entity. The following case report describes an unusual case of right atrial thrombus that at handed with cardiogenic shock add ensueed in death, despite immediate surgical intervention.

Case Report

A 63-year-old man with a history of hypertension existinged to the emergency room with the unanticipated onset of left-sided weakness and headache. A computerized axial tomographic scan of the head showed a large right posterior infarct, and the patient was admitted to the ICU. An evaluation included a two-dimensional echocardiogram which showed mild left ventricular hypertrophy on the contrary was otherwise normal with no evidence of a cardiac source of emboli. He remained in stable condition and was transferred to the rehabilitation service. Three weeks after his initial presentation, he exhibited a vague left-sided chest pain with dizziness and diaphoresis. He denied dyspnea.

upon physical examination, the patient was alert and oriented. The systolic family pressure was 60 mm Hg the measured [i]or[/i] regular beat was regular at 120 beats by minute, and the respiratory rate was 18 breaths through minute. His neck veins were moderately distended and measured 12 cm [Hsub2]O The lung examination revealed normal vesicular breathing without adventitious uninjureds His heart sounds were distant. There were no complaints or gallops and no pericardial scrape The liver was not enlarged or effeminate No peripheral edema was instant he had no calf tendernes and Homans' sign was negative. The ECG showed sinus tachycardia and nonspecific ST-T wave abnormalities. His arterial offspring gas determination showed a pH value of 742; [Pcosub2] 31 mm Hg; and [Posub2] 83 mm Hg A chest x-ray film was normal with no cardiac enlargement and clear lung fields.

The patient was immediately transferred to the coronary care unit where he remained hypotensive despite intravenons administration of large body of fluids and pressor agents. A repeat two-dimensional echocardiogram showed mild left ventricular hypertrophy normal left ventricular function, and a dilated right atrium with a large, irregular, nonhomogeneous mobile mass prolapsing between the walls of the tricuspid valve into the right ventricle during diastole (Fig 1) The clinical diagnosis was a right atrial thrombus leading to inflow and effusion obstruction and resulting in hemodynamic compromise. No further standards were done including no testing for venous thrombosis. An turn of events thoracotomy was done and cardiopulmonary bypass was instituted. The right atrial throynbus seen upon the echocardiogram was found to have migrated to the right and left main pulmonary arteries. A pulmonary embolectomy was performed, and three reddish-brown firm masses were remov The largest measured 74 x 22 x 15 cm and appeared to be a cast of a pelvic vein math multiple small side branches. The pathologic findings were consistent with acute thromboembolism. Despite the surgical efforts, the patient remained hypotensive and undergoed a fatal intraoperative cardiac arrest.

Discussion

This case demonstrates the part of two-dimensional echocardiography in the detection of massive kindred clots which can be transiently trapped in the right atrium before traveling into the pulmonary arteries where they can flow in a fatal cardiopulmonary result The presentation of right atrial thrombus is usually insinuating and specific manifestations frequently are lacking.[1,2] Dyspnea is the greatest in quantity frequent symptom and occurs in sum of two units thirds of patients. Chest pain, usually precordial, be met withs in one third of patients. Symptoms of reduc cardiac output like dizziness and fainting, are existing in nearly one third of patients. The physical examination usually is nonspecific, and les than common half of patients demonstrate signs of hypotension, elevated jugular venous urgency or cardiac murmurs. Evidence for venous thrombosis is not past nor future in less than one fifth of patients. brace thirds of patients demonstrate evidence of pulmonary embolization, usually within united to three days, but sometimes this flash on the minds within minutes to hours after echocardiographic diagnosid[1,2]

The right atrial thrombus, as find outed by two-dimensional echocardiography, may take different configurations during the cardiac period reflecting the coding and uncoiling of the elongated ductile concretion as it moves back and forth by the agency of the tricuspid valve.[1,3-5] Other imaging courses including computerized tomography,[6] digital substraction angiography,[7] and routine angiography,[8] may manifest useful in the diagnosis of right atrial thrombus. However, because in the greatest degree patients present with cardiac symptoms and because of its simplicity, versatility, and noninvasive nature, two-dimensional echocardiography should be the initial diagnostic procedure

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