Jordan Pierce, MD
Resident Physician
University of Central Florida College of Medicine, Graduate Medical Education
Gainesville, Florida
Disclosure information not submitted.
Pheba Cherian, M.D.
Resident Physician
University of Central Florida College of Medicine, Graduate Medical Education. North Florida Regional Medical Center, Internal Medicine Residency Program, United States
Disclosure information not submitted.
Manjot Malhi, M.D.
Resident Physician
University of Central Florida College of Medicine, Graduate Medical Education. North Florida Regional Medical Center, Internal Medicine Residency Program, United States
Disclosure information not submitted.
Crystal Gunn, PA-C
Critical Care Advanced Practice Provider
North Florida Regional Medical Center, United States
Disclosure information not submitted.
Peters Okonoboh, M.D.
Assistant Professor of Internal Medicine
University of Central Florida College of Medicine, Graduate Medical Education. North Florida Regional Medical Center, Internal Medicine Residency Program, United States
Disclosure information not submitted.
Title: Recurrent right ventricular thrombus after successful resection of right ventricular mass
Introduction: Cardiac myxoma, while the most common primary cardiac tumor, typically develops within the left atrium, and rarely in the right atrium or ventricles. Right heart thrombi are associated with significant mortality as they are often found with concurrent pulmonary emboli (PE). We describe a rare case of recurrent massive right ventricular (RV) mass, shown on histopathological analysis as myxoma with blood clot, despite aggressive surgical management.
Description: A 73-year-old woman with recent hospital admissions due to chronic bronchitis and sepsis due to pneumonia presented to our facility with complaint of dizziness. She was found to be in ventricular tachycardia secondary to large bilateral PE with complete occlusion of the pulmonary artery, thrombus within the inferior vena cava, right atrium, as well as an immobile RV mass occupying nearly the entire RV cavity, seen initially on CT chest and confirmed via transthoracic echocardiogram (TTE).
Patient underwent successful emergent surgical resection of the right ventricular mass and pulmonary embolectomy with postoperative recovery of cardiac function and prompt resumption of anticoagulation to limit risk of further thrombi formation. Patient was discharged in stable condition. However, she returned 13 days later with shortness of breath and was found to have heparin induced thrombocytopenia, consumptive coagulopathy and obstructive shock with repeat TTE demonstrating recurrence of large RV mass. Doppler ultrasound of bilateral lower extremities were negative for deep vein thrombosis (DVT) both before and after surgical intervention. Interventional radiology performed mechanical thrombectomy however, was unable to remove the entire mass and the patient subsequently went into PEA arrest and expired.
Discussion: Right heart thrombi form according to three patterns, we believe this patient to have had an unusual case of Type B thrombus with myxoma. Where normally there would be underlying cardiac abnormalities associated with this, she did not have history of such. In addition, the patient experienced rapid, near complete recurrence of the intra-cardiac mass despite surgical resection and anticoagulation in just less than one month’s time. This brings up the question if a different therapeutic approach should be performed with this unusual presentation.