Circulation. 2006;113:e456-e457
doi: 10.1161/CIRCULATIONAHA.105.565903
(Circulation. 2006;113:e456-e457.)
© 2006 American Heart Association, Inc.
Images in Cardiovascular Medicine |
A Left Atrial Appendage Thrombus Mimicking Atrial Myxoma
Barbara Hesse, MD;
Ross T. Murphy, MD, MRCPI;
Jonathan Myles, MD;
Julie Huang, MD;
Ellen Mayer Sabik, MD
From the Departments of Cardiovascular Medicine (B.H., R.T.M., J.H., E.M.S.) and Anatomic Pathology (J.M.), Cleveland Clinic Foundation, Cleveland, Ohio.
Correspondence to Ellen Mayer Sabik, MD, Desk F15, Department of Cardiology, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. E-mail mayere{at}ccf.org
A 58-year-old female with a medical history of 
2 years of chronic atrial fibrillation (on warfarin treatment), previous right mastectomy for invasive ductal carcinoma, and hypertension presented with a hypertensive emergency and mental status changes. Her symptoms resolved with appropriate antihypertensive treatment. The international normalized ratio on presentation was 2.9. During an additional work-up for transient neurological symptoms, transesophageal echocardiography was performed, revealing a 2x2-cm, well-circumscribed, spherical, mobile echodensity within the ostium of the left atrial appendage (LAA), which was attached by an 8-mm–long stalk to the lateral wall of the appendage (Figure 1). Continuous, mild-to-moderate spontaneous echo contrast was noted in the left atrium and LAA, and the peak emptying velocity in the appendage was 10 cm/s (Figure 2). It was unclear whether the mass represented a thrombus or an unusually located atrial myxoma. The patient underwent uncomplicated excision; the operative report describing a "mass floating around the atrium, attached with a very fine pedicle to the left atrial appendage" (Figure 3). Pathological findings disclosed an organizing thrombus (Figure 4). Of note, the entire specimen was examined histologically, because portions of myxoma may look similar to an organizing thrombus. In this case, there was no accumulation of myxoid material, and no stellate cells characteristic of myxoma were found anywhere in the specimen.
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Figure 1. Transesophageal echocardiogram depicting a circular mass attached to the lateral wall of the LAA by a distinct stalk.
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Figure 2. Pulse-wave Doppler echocardiogram in the LAA, demonstrating a low peak emptying velocity of only 10 cm/s.
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Figure 3. In situ operative field with the view into the LAA, again showing the circular mass with a pearly white, shiny surface, with attachment to the LAA wall by a fine pedicle.
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Figure 4. Low-magnification (x40, A) and high-magnification (x100, B) views from the pathological examination; hematoxylin and eosin stain. The pink-red center is the thrombus; the whiter and blue sections at the edge are granulation tissue, illustrating the process of thrombus organization that progresses from the outside in.
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This is a case of an unusual macroanatomic appearance of an LAA thrombus with a distinct, long stalk in a patient on therapeutic anticoagulation. The definite differentiation from an atypically located atrial myxoma could only be made with certainty from a very careful histopathological examination.
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Acknowledgments
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Disclosures
None.
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Footnotes
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The online-only Data Supplement can be found at http://circ.ahajournals.org/cgi/content/full/113/11/e456/DC1.
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Issue Highlights
Circulation 2006 113: 1377.
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