European Journal of Echocardiography 2008 9(1):95-96; doi:10.1016/j.euje.2007.03.029
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org.
Diagnosis of right atrial mass by perioperative transesophageal echocardiography
Cassiano Moro1,
Andrew Klein1,*,
Kumud Dhital2 and
Julian Gooi2
1 Department of Anaesthesia, Papworth Hospital NHS Trust, Papworth Everard, Cambridge CB23 3RE, UK
2 Department of Cardiothoracic Surgery, Papworth Hospital NHS Trust, Papworth Everard, Cambridge CB23 3RE, UK
Received 9 February 2007; accepted after revision 11 March 2007; online publish-ahead-of-print 10 May 2007.
* Corresponding author. Tel: +44 7971687764. E-mail address: andrew.klein{at}papworth.nhs.uk
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Abstract
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A 67-year-old lady presented with shortness of breath, and was
found to have severe triple vessel disease by coronary angiography.
Transthoracic echocardiography (TTE) was reported as normal.
However a large cystic mass was unexpectedly found in the right
atrium by intra-operative transesophageal echocardiography (TOE).
This mass was attached to the anterior wall, just by the inter-atrial
septum. Flow was demonstrated within the mass by colour flow
doppler. The right atrium was opened and the mass excised during
cardio-pulmonary bypass. A right coronary artery aneurysm was
diagnosed, which was confirmed on histopathological examination.
The importance of intra-operative TEE in demonstrating new findings
and changing management is highlighted. Coronary artery aneurysm
may predispose to embolism or thrombosis if untreated, and may
not be seen on angiography or TTE, as in this case.
Keywords: Right coronary artery; Aneurysm; Transesophageal echocardiography
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Case report
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A 67-year-old lady presented to the cardiologists with shortness
of breath on exertion. Her past medical history included hypertension,
non-insulin dependent diabetes mellitus and myocardial infarction
(7 months previously). Coronary angiography demonstrated triple
vessel coronary artery disease, not amenable to percutaneous
management, with no other pathology identified. Transthoracic
echocardiography showed a dilated sinus of Valsalva (4.4 cm),
dilated right and left atria and preserved ventricular function.
Significant carotid artery disease was also discovered on carotid
duplex scan, which was treated by uncomplicated right carotid
endarterectomy under local anaesthesia.
Coronary artery bypass grafting was scheduled electively. Intra-operative trans-oesophageal echocardiography (TOE) revealed a 4.1 x 3.6 cm cystic mass in the right atrium (Figures 1 and 2), which appeared to arise from the anterior atrial wall, just anterior to the inter-atrial septum. This was best seen in the bicaval view; doppler echocardiography demonstrated blood flow within the mass. Once sternotomy had been performed, the mass was palpable in the right atrium. After institution of cardio-pulmonary bypass, the right atrium was opened and explored. The mass was found to arise from the triangle of Koch and the inter-atrial septum. Further dissection revealed this to be a right coronary aneurysm and the vessel connecting the aneurysm to the right coronary artery was isolated and divided (Figure 3). The aneurysm was then excised and the inter-atrial septum patched with pericardial tissue. The operation then proceeded uneventfully. Postoperative recovery was uncomplicated and the patient was discharged home 10 days later.
Histopathology demonstrated a well-defined haemorrhagic mass
measuring 5
x 4
x 4 cm (
Figure 4). Inside the mass was
organized thrombus surrounded by fibroelastic and fibrous tissue,
and a feeding vessel at the base of the lesion was seen.
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Discussion
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Coronary artery aneurysm is defined as coronary artery dilatation
with a diameter of 1.5 times or more that of the adjacent normal
vessel. It is thought to occur in fewer than 5% of patients.
1 The proximal and middle segments of the right coronary artery
are most frequently involved. Involvement of the left main coronary
is rare. Men are affected more commonly than women.
The most common aetiology in the adult patient is atherosclerosis. Aneurysmal dilatation of saphenous vein bypass grafts is also well described.2 Other causes include Kawasaki's disease, iatrogenic after diagnostic or interventional coronary angiography, inflammatory and infectious arteritis, connective tissue disease, aortic dissection, tumour, trauma and congenital malformation. The proximal and middle segments of the right coronary artery are most commonly involved, followed in frequency by the proximal LAD and circumflex arteries.3 The clinical presentation is often silent but patients may complain of angina or shortness of breath. The altered blood flow in aneurysmal segments is thought to predispose to thrombosis or embolism and subsequent ischaemia or infarction.4 Therefore coronary aneuryms are usually managed surgically, often concurrent with coronary artery grafting.
This case report demonstrates the importance of TEE intra-operatively. This aneurysm had not been demonstrated pre-operatively on angiography or transthoracic echo. Transthoracic echo may not visualise masses in the right atrium as clearly as TEE because of the distance of the structure from the probe. TEE was able to view the mass clearly and demonstrate its size and location, assisting the surgeons in managing this unexpected finding. In this instance had TEE not been used, the surgeon would have been able to palpate the mass during preparation for cannulation, and would have made the diagnosis upon opening the right atrium. However in other cases an aneurysm might not be so large or easily palpable, but would be found by TEE. Therefore potential complications, such as thrombosis or embolism, may be prevented.
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Supplementary material
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Supplementary material associated with this article can be found in the online version.
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References
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- Danner B, Horst M, Ghosh P, Dapunt O. Right atrial mass: tumour or aneurysm? Int Cardiovasc and Thorac Surg (2003) 2:352–4.[CrossRef]
- Swaye PS, Fischer LD, Litwin P, Vignola PA, Judkins MP, Kemp HG, et al. Aneurysmal coronary disease. Circulation (1983) 67:134–8.[Abstract/Free Full Text]
- Sridharan S, Mandell B. Myocardial infarction in a 24 year old woman. Cleve Clinic J Med (2001) 68:688–702.
- Syed M, Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis (1997) 40:77–84.[CrossRef][Web of Science][Medline]
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