Sinüs ritminde kalp yetersizliği olan bir hastada sağ atriyal apendiks içinde trombüs

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Introduction
Intracardiac masses are often incidentally detected during imaging studies. A tumor, thrombus, or
vegetation may be seen as an intracardiac mass (1).
Thrombus can be located within atrial cavities, ventricular cavities or both. Within the atria, thrombus
can be found in appendages, body of the atrium or in
a combination of these areas (2). We, herein, report a
21-year-old male patient with a right atrial appendage (RAA) thrombus.
Case Report
A 21-year-old male was admitted to our clinic with
exertional dyspnea and fatigue. His previous cardiac history was unremarkable. We detected faint heart
sounds and grade 2/6 apical systolic murmur during
physical examination. The admission electrocardiography (ECG) and holter monitoring demonstrated
sinus rhythm (Figure 1). Cardiothoracic index was
found to be increased on chest X-ray. Transthoracic
echocardiography revealed biventricular failure (Left
ventricular EF: 10%, Right ventricular TAPSE 11 mm),
mild mitral insufficiency, mild to moderate tricuspid
insufficiency and suspicious mass in the right atrium.
Further imaging study with transesophageal echocardiography (TEE) revealed prominent spontaneous
echo contrast (SEC) within the right atrium and a fresh
thrombus reaching 20x25 mm diameter located at the
right atrial appendage (Figure 2). Left atrial appendage
was free of thrombus. All biochemical test results including homocysteine levels were within normal limits.
Prothrombin time, activated partial thromboplastin
time, lupus anticoagulant, anti-cardiolipin antibody,
fibrinogen levels and hereditary conditions that increase the tendency to thrombus formation including factor V leiden, protrombin gene mutation and methylenetetrahydrofolate reductase gene mutation were found normal. Doppler ultrasonography was performed
and deep vein thrombosis was excluded. Coronaryangiography was normal. We decided that the patient
had idiopathic dilated cardiomyopathy and appropriate therapy was given including warfarin. Second TEE
examination at the third month revealed a decrease in
thrombus size and we decided to continue the therapy.
Discussion
Intracardiac thrombus may develop as a consequence of multiple underlying cardiac disorders. Atrial fibrillation is a major underlying predisposing factor in
patients with a right atrial appendage thrombus (2,3).
However, our patient was in sinus rhythm which makes the presence of right atrial apendage thrombus an
unusual finding. We can speculate that right ventricular dysfunction may cause right atrial appendage
thrombus because of low flow state. Dilated cardiomyopathy is associated with poor atrial emptying and
blood stasis resulting in intracardiac thrombus. The
most frequent location of the thrombus in patients
with dilated cardiomyopathy is the left ventricle (2).
Our patient also had SEC in the right heart chambers.
We thought that the presence of SEC was the predisposing factor for thrombus development (4). Indeed,
de Divitiis et al. reported SEC as the only independent predictive factor for RAA thrombus (3).
Figure 1. Electrocardiography showing sinus rhythm
Figure 2. Transesophageal echocardiography showing a fresh
thrombus located at the right atrial appendage
In conclusion, a right atrial appendage thrombus
may develop in right heart failure patients without
atrial fibrillation and TEE has superior diagnostic utility in such cases.