Large Thrombus Formation from Right Atrial Incision Site after Closure of Atrial Septal Defect
A 42-year-old female, without cardiac complaints, was admitted to our clinic presented with chest discomforts, one month history of exertional dyspnea and persistent dry coughs. She had a history of primary ASD repair 3 years ago, and quitted routine follow-ups. In her previous primary repair surgery, the defect was closed directly with an atriotomy incision followed by 5/0 polypropylene and 4/0 polypropylene sutures. The patient had attended her ensuing controls every two months for a period of one year, and no pathological findings were identified during this period. Biochemical and hematological values were within normal limits. Cardiovascular examination was normal and no pathologic sounds or murmurs were detected. The patient was in normal sinus rhythm and not on any medications. Chest examination elicited few scattered crepitations bilaterally. An image from contrast-enhanced CT pulmonary angiogram demonstrated multiple bilateral pulmonary emboli. TTE revealed normal left ventricular systolic functions, heart chambers within normal size, and a mass in the right atrium. On TEE examination, a 3.2×2.4 cm mobile and irregularly-shaped mass was observed in the right atrium. The patient's bilateral Doppler of lower extremity, abdominal ultrasonography, and hypercoagulability screening panel was negative. Excision of the mass with redo sternotomy was decided for treatment. During the surgery, exploration of the right atrium revealed a 3.2×2.3 cm globular mass with a tanned, gelatinous appearance and multifocal areas of calcification. The mass was attached to the free wall of the right atrium by a 1-cm stalk. This mass originating from the free wall of the right atrium was then excised and its histological examination later revealed it to be an organized thrombus. Both patients had uneventful postoperative courses, and were discharged with warfarin (international normalized ratio: 2-3) combined with acetylsalicylic acid therapy on postoperative seventh and sixth day, respectively. The TTE and TEE showed no thrombus after 6 months of follow-up for both patients.