Cas du 22/03/2015: Right Atrial Sediment

 

Presentation: A patient with atrial fibrillation scheduled for a CABG w/ECC had this loop of his right atrium.

#1: What is your differential diagnosis?
#2: What is the most likely diagnosis?
#3: Could you perform cardioversion on this patient?

















Explanation: The differential diagnosis for a right atrial mass is thrombus, lipoma, artifact, myxoma, vegetation, and tumor.  A linear mass would make it more likely to be a thrombus, lipoma or artifact.  Myxomas, vegetations and tumors do not tend to be linear.  Since the patient is in atrial fibrillation, this most likely represents a thrombus.  Lipomas tend to be more echogenic whereas thrombi tend to be more echo lucent (probably because they are made of blood products sitting in a pool of blood).  Atrifacts or pitfalls would include right atrial pectinate muscles and shadowing from another structure.

Cardioversion is used to convert patients in atrial fibrillation to normal sinus rhythm.  In patients with RA thrombi who are anticoagulated and who do not have a right to left shunt, the risk of stroke or pulmonary embolus is low.  However, patients with RA spontaneous echo contrast and RA thrombi tended to have recurrence of their atrial fibrillation when compared to patients without SEC or RA thrombi.
 

Article sur les masses cavités droites
https://www.dropbox.com/s/j08au879cacf9b5/Echocardiography%20Volume%2027%20issue%209%202010%20%5Bdoi%2010.1111%252Fj.1540-8175.2010.01264.x%5D%20Marina%20Leitman%3B%20Ehud%20Rahanani%3B%20Ilan%20Wassermann%3B%20Simha%20Rosenblatt%20--%20Unusual%20Right-Sided%20Cardiac%20Masses.pdf?dl=0
Et le lien vers les vidéos de l'article:
http://onlinelibrary.wiley.com/doi/10.1111/j.1540-8175.2010.01264.x/suppinfo

Article sur les masses OD:
https://www.dropbox.com/s/edgwtcsz0hyc17x/Echocardiography%20Volume%2022%20issue%205%202005%20%5Bdoi%2010.1111%252Fj.1540-8175.2005.04049.x%5D%20Michael%20S.%20Chen%3B%20Jing-Ping%20Sun%3B%20Craig%20R.%20Asher%20--%20A%20Right%20Atrial%20Mass%20and%20a%20Pseudomass.pdf?dl=0

 Article sur le CS et les thrombi intra-OD dans le cadre du traitement de la FA:
https://www.dropbox.com/s/97ryrfbgkyh3srp/Journal%20of%20the%20American%20Society%20of%20Echocardiography%20Volume%2014%20issue%202%202001%20%5Bdoi%2010.1067%252Fmje.2001.108668%5D%20Bashir%2C%20Mohammad%3B%20Asher%2C%20Craig%20R.%3B%20Garcia%2C%20Mario%20J.%3B%20Abdalla%2C%20Ib%20--%20Right%20Atrial%20Spontaneous%20.pdf?dl=0


Remarque:
Concernant la cardio-version en cas de thrombus OD, dans tous les articles que j'ai lu, les patients ont en bénéficié qu'après disparition des thrombi sous anticuoagulation.