Kalıcı kalp pili takılması sonucu gelişen ve pulmoner emboliye yol açan triküspit kapak üzerinde yerleşik trombüs

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Introduction
Tricuspid valve thrombus is a rare finding particularly in normal heart and may mimic cardiac tumors.
We, herein, report a 36-year-old man with a thrombus of the tricuspid valve developing one year after a
permanent pacemaker implantation.
Case Report
A 36-year-old male who had a pulmonary embolus
was transferred to our clinic from a regional hospital
for the determination of the embolic source. He was
taking intravenous heparin for four days at the time
of admission. He had a previous history of ventricular septal defect (VSD) repair and a DDDR pacemaker implantation related to postoperative complete
AV block one year ago. His physical examination
was unremarkable with a grade 2/6 systolic murmur
at the left lower sternal area. Electrocardiography
(ECG) revealed sinus rhythm with nonspecific ST/T
changes. Complete blood count, sedimentation and
routine biochemistry tests were within normal limits. Transthoracic echocardiography (TTE) showed
a mobile mass at the close vicinity of the pacemaker. Transesophageal echocardiography (TEE) revealed a 15 mm mobile thrombus with irregular shape
attached to the anterior leaflet of the tricuspid valve (Figure 1). We examined closely his preoperative
echocardiography records and did not find any clue
about a right atrial mass. The patient refused surgical
intervention, so medical therapy including warfarin
was recommended.
Discussion
A mass on tricuspid valve can be a thrombus, a tumor or vegetation (1). We excluded the vegetation
possibility because of clinical findings not suggesting an infectious cause. Although a papillary fibroelastoma can be located in tricuspid valve, this kind
of involvement is more frequent in children (2).
* Cardiology Service, Malatya Military District Hospital
** Department of Cardiology, Gulhane Military Medical Faculty
Reprint request: Dr. Barış Buğan, Department of Cardiology, Malatya Military
District Hospital, Malatya, Turkey
E-mail: bbugan@hotmail.com
Date submitted: August 18, 2010 • Date accepted: September 22, 2010Volume 53 • Issue 1 A thrombus located at the tricuspit valve • 51
Moreover, echocardiographic appearance of the mass
in our patient was not suggestive of a papillary fibroelastoma (3). There is no typical echocardiographic feature, which can be used in differentiating a
thrombus from a papillary fibroelastoma. Indeed, a
papillary fibroelastoma can be mobile and has irregular shape with stalk as in our case. It can also cause pulmonary embolism. Unfortunately, we did not
have pathologically supported evidence for a thrombus. Nevertheless, we suggested that tricuspid valve
trauma related to pacemaker lead insertion leads to
thrombus development in our patient. We also thought that the absence of right atrial mass presence
in previous echocardiography reports supported our
suggestion as well.