rhythm, chronic heart failure with preserved ejection fraction, and non-obstructive coronary artery disease. Physical exam was noted for jugular venous distention, irregularly irregular tachycardia, laterally displaced PMI, high-pitched holo-systolic blowing apical murmur, tachypnea with mild use of accessory muscles, and 2+ bilateral pretibial edema. His chest X-ray showed a mildly enlarged cardiac silhouette. Electrocardiogram demonstrated atrial fibrillation with rapid ventricular rate of 122 and right axis deviation. He was admitted for management of acute decompensated heart failure. He was started on IV furosemide with adequate response. Transthoracic echocardiogram showed global left-ventricular hypokinesis with an ejection fraction of 40%, severe bileaflet mitral valve prolapse with resultant severe mitral valve regurgitation. Transesophageal echocardiogram prior to planned cardioversion revealed a 45mm x 25mm right atrial mass adherent to the right atrial appendage (non-enhancing with perflutren contrast and no color flow doppler signals)
and severe eccentric mitral regurgitation. Differentials were broad of right atrial mass and included concern for thrombus, benign myxoma and primary versus metastatic carcinoma. CT pulmonary angiogram excluded pulmonary embolism. Once his heart failure and atrial fibrillation were medically optimized, preoperative angiography confirmed non-obstructive coronary artery disease. Shortly after, he underwent surgical mitral valve replacement, Cox Maze to restore sinus rhythm, left atrial appendage resection and right atrial mass resection. Pathological analysis of mass revealed findings of large mural thrombus. Discussion: Right atrial thrombi are less common due to the shallow anatomy of the right atrial appendage. Some other conditions which can predispose to right atrial thrombus formation include tricuspid stenosis or a tricuspid valve prosthesis. The majority of patients with right atrial thrombi also have left atrial thrombi, thus cardioversion should be deferred even if patients have isolated right atrial thrombi.
PERSISTENCE MAY NOT BE THE KEY TO SUCCESS: A COMMON RISK OF HEMOPERICARDIUM FROM ICD PLACEMENT Michelle Livitiz, Logan Gold, Ian Denys, Ashley Misky, Trent Davidge, Panicker Renni Robinson, Eduardo Venegas, Neeraj Jain; Department of Medicine, LSU Health Sciences Center, New Orleans, LA.
Introduction: A persistent left superior vena cava (PLSVC) is a congenital vascular anomaly where the left superior cardinal vein caudal to the innominate vein fails to regress and is present in about 0.5% of the population. Implantable cardiac defibrillator (ICD) placement is especially challenging in these patients. In this population, hemopericardium following ICD placement is likely a result of direct injury to the coronary sinus. Case: 48-year-old male with severe nonischemic cardiomyopathy with LBBB status post elective dual chamber ICD placement five days prior presented for persistent globus pharyngeus several hours after eating pizza. Patient had chest tightness and diaphoresis in the ED, with marked improvement of both after an emetic episode. A bedside echo incidentally found a pericardial effusion (PE), and CT imaging noted its density was similar to blood. The ICD placement op note described a failed attempt to place a CRT “given lack of lateral coronary sinus branches due to a congenital anomaly (PLSVC).” During the procedure, there was difficulty maneuvering in the coronary sinus.
Formal echo showed a moderate PE with coagulum. Cardiac CTA revealed no contrast extravasation into the pericardium. Serial imaging studies showed minimal interval changes in effusion volume, likely from a microtear causing a venous bleed from the coronary sinus during ICD placement. Throughout the patient’s hospital course, he was asymptomatic aside from his presenting symptom of dysphagia. Discussion: ICD placement in patients with congenital cardiovascular anomalies requires care and a planned approach to minimize complications. In this patient, there was no bridging vein connecting the bilateral super vena cavae, so the PLSVC was utilized for left pectoral device placement. During ICD placement, this patient did not have the lateral branches of the coronary sinus suitable for LV lead location. Coronary sinus dilatation associated with PLSVC and repeated attempts to deliver the LV lead is speculatively associated with microperforation and hemopericardium in this case. If PLSVC is diagnosed prior to device implantation, CT venography may be of high utility to guide procedural planning and minimize the risk of adverse procedural outcomes. 15
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