61-year-old man with a history of asthma, colon cancer s\/p hemicolectomy (on Xeloda), COPD, presenting with chief complaint of abdominal pain, non-exertional chest pain, and dyspnea. He denied fever, chills, cough, nausea, vomiting, diarrhea, or dysuria. He was recently hospitalized at an outside hospital for pancreatitis and ascending cholangitis and was treated with antibiotics and underwent an ERCP. He reported that he had completed the antibiotics and was taking rivaroxaban after being told he had a blood clot in his heart. He opted for a patient-directed discharge from that hospital but is re-presenting today for symptoms stated above. His port had been in place since 06\/26\/2024.
Vitals:<\/strong>
T 98F, HR 87, BP 105\/68, RR 16, SpO2 99%
Physical Exam:<\/strong>
Physical exam was notable for no apparent distress, port over right anterior chest without tenderness to palpation, warmth, or erythema. Cardiovascular exam with normal rate, regular rhythm without murmurs, rubs, or gallops. Lungs were clear without crackles or wheezing. Abdomen was soft and non-tender. There was no LE edema.
Labs:<\/strong>
Labs without leukocytosis or anemia
ALT 49
AST 42
ALP 144
T bili 1.38
Troponin within normal limits
A bedside ultrasound was performed.
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![\"\"](\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2024\/11\/image.png?resize=423%2C312&ssl=1\")
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What do you see?
Figure 1: Apical four chamber view demonstrating hyperechoic mass in right atrium.
Discussion<\/strong>
Bedside ultrasound demonstrated a hyperechoic mass in the right atrium, consistent with records from the outside hospital. A CTPE was also performed which showed no evidence of pulmonary embolism, but did demonstrates a 3.2 cm filling defect in the right atrium corresponding to the previously identified right atrial thrombus at the outside hospital. He also had an abdominal ultrasound which demonstrated a surgically absent gallbladder, no hydronephrosis or calculi, patent portal vein, and no ascites or space occupying lesions. Cardiology was consulted, and given improvement in his symptoms he was discharged with return precautions and recommendations to continue anticoagulation with close follow up for a repeat TTE in the outpatient setting.
Cardiac masses are not common. While they can sometimes present without symptoms, particularly for patients with pacemakers or central lines, they should remain on the differential for patients presenting with unexplained fever, dyspnea, catheter dysfunction, or a new murmur. It is important to recognize catheter associated thrombi as they are associated with increased morbidity and mortality, and can lead to bacteremia, catheter malfunction, SVC syndrome, pulmonary embolism, paradoxical emboli, and prolonged hospitalization and increased cost of care (1).
Specifically within the right atrium, normal anatomy can mimic tumors. The differential for right atrial masses includes benign or malignant neoplasms, myxoma, fibroelastoma, lipoma, cyst, vegetation, or thrombus (2). As demonstrated in this case, pacemaker leads and indwelling catheters in the right atrium can place patients at risk for thrombi or vegetations.1 While this patient had a history of malignancy, it was not known to be metastatic, and the proximity of the mass to the catheter was more suggestive of catheter associated thrombus. Evaluation of right atrial masses includes chest radiography, TTE, and TEE. POCUS is a non-invasive and useful tool that can aid in identifying and visualizing the size, location, and mobility of masses. POCUS can also be utilized to evaluate presence of obstruction or filling defects. Additional evaluation may involve cardiac MRI, computed tomography (CT), or positron emission tomography (PET) to further characterize masses when the etiology remains unclear (3). Management of atrial masses depends on the etiology. In the case of catheter- associated thrombus, management can include anticoagulation, thrombolysis, thrombectomy and eventual removal of the catheter (4).
One prior case report demonstrated the utility of POCUS for quickly diagnosing a catheter associated thrombus, allowing for timely initiation of anticoagulation to prevent further complications such as pulmonary embolism (5). Similarly, this case demonstrates the utility of POCUS in the Emergency Department to identify a recently diagnosed catheter associated thrombus without any significant increase in size or subsequent complications. This allowed for the patient to be discharged in a timely manner and avoid repeating further imaging studies.
1. Geerts W. Central Venous Catheter-Related Thrombosis. http:\/\/ashpublications.org\/hematology\/article-pdf\/2014\/1\/306\/1250721\/bep00114000306.pdf
2. Sharma S, Narula N, Argulian E. Solving the Diagnostic Challenge of Right Atrial Mass. JACC Case Rep. 2022;4(4):236-238. doi:10.1016\/j.jaccas.2022.01.003
3. Parwani P, Co M, Ramesh T, et al. Differentiation of Cardiac Masses by Cardiac Magnetic Resonance Imaging. Curr Cardiovasc Imaging Rep. 2020;13(1). doi:10.1007\/s12410-019-9522-4
4. Tran MH, Wilcox T, Tran PN. Catheter-related right atrial thrombosis. Journal of Vascular Access. 2020;21(3):300-307. doi:10.1177\/1129729819873851
5. Nelson EL, Greenwood-Ericksen M, Frasure SE. Point-of-care ultrasound diagnosis of a catheter-associated atrial thrombus. Journal of Emergency Medicine. 2016;50(2):e75-e77. doi:10.1016\/j.jemermed.2015.06.063
<\/p>\n","protected":false},"excerpt":{"rendered":"Charlotte Ellberg, MD History:61-year-old man with a history of asthma, colon cancer s\/p hemicolectomy (on Xeloda), COPD, presenting with chief complaint of abdominal pain, non-exertional chest pain, and dyspnea. He denied fever, chills, cough, nausea, vomiting, diarrhea, or dysuria. He was recently hospitalized at an outside hospital for pancreatitis and ascending cholangitis and was treated …