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Left atrial thrombus due to transseptal catheterization simulating solid mass of right atrium
© The Author(s). 2017
Received: 16 October 2016
Accepted: 26 July 2017
Published: 1 September 2017
Transseptal catheterization has been popularized through ongoing advances in percutaneous procedures, but related complications are known to occur.
A 72 year-old female was admitted with left-sided weakness. In the course of various exams, a rounded and smooth-surfaced solid mass of right atrium was identified. However, a septal aneurysm associated with left atrial mural thrombus was evident intraoperatively. Given that percutaneous transseptal mitral valvotomy had been done 7 years previously, a causal relationship is likely.
Prior cardiac intervention should be considered in patients presenting with mass lesions of interatrial septum.
In the late 1950s, Ross et al. introduced transseptal catheterization for evaluating valvular heart disease . Recent advances in this percutaneous procedure have enabled treatment of arrhythmia, valvular and congenital disorders through such interventions to avoid open heart surgery. Nevertheless, a transseptal approach is not without complications, namely persistent iatrogenic atrial septal defects, cardiac tamponade, and rupture [2, 3]. Reported herein is the discovery of a left atrial thrombus found years after transseptal catheterization and clinically misinterpreted as a solid mass of right atrium. The thrombus had formed within a septal aneurysm.
A 72-year-old female was admitted for left-sided weakness. Magnetic resonance imaging (MRI) of the brain disclosed multifocal acute infarcts of right insular and peri-insular regions, right temporal cortex and ipsilateral postcentral gyrus, and right middle cerebral arterial supply. Vital signs were stable, and electrocardiogram showed atrial fibrillation without rapid ventricular response. The patient unmonitored at the time had undergone percutaneous mitral valvotomy for rheumatic mitral stenosis 7 years earlier at another institute. But, she has not been to the hospital since then and has not taken any medication, including anticoagulants.
Interatrial septal repair took place directly thereafter (cardiopulmonary bypass, 207 min; aortic cross-clamping, 28 min; total circulatory arrest, 15 min; rectal temperature, 20 °C). No additional procedures were warranted. The patient was discharged 12 days postoperatively, without complications, and the 2 years since have been uneventful. Final pathology review confirmed a cystic mural thrombus (2 × 1.5 × 1.3 cm), clinically simulating a mass of right atrium.
As percutaneous procedures continue to evolve, transseptal catheterization has become popular for treating arrhythmias or mitral valvular disease. However, certain procedural complications are inherent [2, 3]. The catheter placed inside RA generally enters LA via patent foramen ovale or transseptal puncture. Such iatrogenic septal defects may prove detrimental in some patients.
Atrial septal aneurysm (ASA) is an infrequent finding in adults, linked to systemic embolism on occasion . Furthermore, Aksnes et al. have reported on surgical excision of an ASA after a cerebral embolic episode . The ASA in our patient had gradually filled with thrombus, protruding into RA. Both location and size made it difficult to accurately characterize. Without operative treatment, the exposed fresh thrombus of left atrium virtually ensured recurrent embolic insults. Even gentle intraoperative manipulation may have precipitated immediate postoperative stroke.
Prior transseptal intervention should be considered in patients presenting with mass lesions of interatrial septum. Required surgical excision calls for extreme care to prevent perioperative systemic embolization.
The authors declare that they have no funding.
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Lee JH is the lead surgeon on this case and wrote the manuscript. Kim J-H provided echocardiographic and radiologic findings. Choi J-H and Kim E-J performed the literature review and participated in the manuscript writing. All authors have read and approved the final manuscript.
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