European Journal of Echocardiography Advance Access originally published online on February 22, 2008
European Journal of Echocardiography 2008 9(4):572-574; doi:10.1093/ejechocard/jen007
Published on behalf of the European Society of Cardiography. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Thrombus entrapped in tricuspid chordae masquerading as tumour
Ali Reza Moaref1,
Reza Mollazadeh1,*,
Ahmad Ali Amirghofran2 and
Mehra Modjallal3
1 Cardiology Department, Nemazee Hospital, Shiraz University of Medical Science, Shiraz, Fars, Iran
2 Cardiac Surgery Department, Nemazee Hospital, Shiraz University of Medical Science, Zand Avenue, Shiraz, 71435-1414 Fars, Iran
3 Pathology Department, Dena Hospital, Shiraz, Fars, Iran
Received 7 August 2007; accepted after revision 23 October 2007; online publish-ahead-of-print 22 February 2008.
* Corresponding author. Tel: +98 917 313 3749; fax: +98 711 6261089. E-mail address: mollazar{at}yahoo.com
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Abstract
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We report on a 55-year-old man with effort dyspnoea that transesophageal
echocardiography disclosed was due to a mass originating from
the chorda of the tricuspid valve. Histological examination
revealed the mass to be an organized thrombus without tumour
components. This case illustrates the unusual presentation of
a thrombus confined to the tricuspid chordae mimicking a chordae
tumour.
Keywords: Tricuspid valve; Chorda; Tumour; Thrombus
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Case presentation
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A 55-year-old man was admitted in our hospital for investigation
of an abnormal mass shadow revealed in a transthoracic echocardiogram.
He didn't have any cardiovasular symptoms until 3 months before
admission and then developed dyspnoea on exertion. He was visited
by a pulmonologist and treated as a case of interstitial lung
disease, but showed no improvement. Additional symptoms such
as becoming easily tired and chest pain developed. Throughout
his stay, he remained afebrile. Physical examination was unremarkable.
ECG and chest X-ray were normal. Three sets of blood cultures
taken, all of which were negative. Erythrocyte sedimentation
rate (ESR) and C-reactive protein (CRP) values remained normal.
Transthoracic echocardiography showed a large mass in the right
ventricle. Complementary transesophageal echocardiography disclosed
the tumour's attachments to the chordae tendineae (
Figure 1,
see
Supplementary data online, Movie 1). Our assumption was
that the micro-embolization from the tumour was the source of
his symptoms, so we decided to resect the mass to prevent massive
pulmonary embolism. He underwent surgery with cardiopulmonary
bypass; a fleshy irregular-shaped mass entrapped in the tricuspid
chordae was discovered (
Figure 2). No other adhesion to
the right atrium or ventricle structure was observed. The mass
was resected completely with a part of the associated papillary
muscle. Tricuspid valve competency was achieved with the use
of ring annuloplasty and artificial chordae. Histopathological
examination of the mass revealed an organized thrombus (
Figure 3A)
with neo-vascularization but without any evidence of tumour
cell components (
Figure 3B). His post-operative course
was uneventful.
Cardiac valve tumours are rare and usually asymptomatic. Transthoracic
echocardiography and transesophageal echocardiography are useful
in detecting valve tumours. In our case, the tumour was initially
identified as a right ventricular mass, but transesophageal
echocardiography showed the tumour originating from the chordae
tendineae of the tricuspid valve. Edwards
et al.1 reported 73%
of all valvular tumours to be papillary fibroelastomas. However,
in our case, there was neither pedicle nor the typical stippled
edge at the tumour–blood interface, which is detectable
and essential for non-invasive diagnosis of this sea anemone-like
tumour.
2 Other less common masses are vegetation, myxoma, thrombi,
and calcifications.
We attributed the thrombus in our patient to the entrapment of a thrombo-embolus during transit from the deep leg veins to the pulmonary artery in the chordae tendineae, or, although less likely, it could due be to thrombus formation in a structurally normal heart. Our case was unique in that the thrombus was confined to the chordae tendineae.
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References
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- Edwards FH, Hale D, Cohen A, Thompson L, Pezzela AT, Virmani R. Primary cardiac valve tumors. Ann Thorac Surg (1991) 52:1127–31.[Abstract]
- Dehnee AE, Brizendine S, Herrera CJ. Recurrent strokes in a young patient with papillary fibroelastoma: a case report and literature review. Echocardiography (2006) 23:592–5.[CrossRef][Web of Science][Medline]
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Abstract
Case presentation
