Title Prominent Crista Terminalis Presenting As a Right Atrial Mass
Authors Hunter Launer, MD. Hanyuan Shi, MD. Rogin Subedi, MD.
Introduction Right atrial masses can represent thrombi, myxomas (although more commonly on the left side), fibroelastomas, tricuspid valve vegetations, and benign structural abnormalities. Routine transthoracic echocardiography (TTE) can often pick up right atrial abnormalities, but often need multiplanar imaging to clearly elucidate between a pathological process and artifact. Case Presentation A 93 year-old woman with a history of atrial fibrillation on anticoagulation initially presented for fall and confusion. She was tachycardiac but otherwise hemodynamically stable. CT brain and MRI brain were negative for acute intracranial processes. As part of a syncope work-up, TTE with contrast was done showing a large, fixed, echodense mass (1.4 x 2.2cm) visualized in the right atrium. Dabigatran was continued given concern that this mass was a thrombus. Cardiac MRI non-stress done with and without contrast showed 4 non-dilated cardiac chambers without mass or thrombus present. There was a prominent crista terminalis, without evidence of abnormal delayed gadolinium enhancement (DGE). Given this result, transesophageal echocardiogram was not performed. Discussion The crista terminalis is a muscular ridge in the posterolateral aspect of the atrium on the right side and can be considered a pseudomass that shows up on TTE. Interestingly, the crista terminalis is usually benign, but the changes of velocity and conduction near this ridge can make some patients more prone to cardiac arrhythmias. There have been a few reports of misdiagnoses of right atrial masses from TTE alone, and contrast TTE can sometimes differentiate if there are vascular components of the mass, but better elucidation with cardiac MRI, cardiac CT, or transesophageal echocardiography (TEE) is usually needed for diagnosis. Especially in this case, cardiac MRI is better able to capture invagination of the right atrial walls and separate out if there are actual stalks or neoplasms present. Conclusion A prominent cristal terminalis can present as a hypodense right atrial pseudomass, which is a benign finding. However, patients with a history of arrhythmia should undergo further testing with cardiac MRI or TEE to rule-out thrombus and tumor.
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