European Journal of Echocardiography Advance Access published online on February 22, 2008
European Journal of Echocardiography, doi:10.1093/ejechocard/jen007
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Thrombus entrapped in tricuspid chordae masquerading as tumour
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.
* 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 material 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.
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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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- 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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