James Choi Toby Speirs Ranvir Bhatia Sanjay Sivalokanathan Colin Craft

Abstract

Atrial fibrillation, the most common cardiac arrhythmia in the Western world, confers a 5-fold increase in stroke, mainly due to thrombus formation in the left atrial appendage. Early rhythm control is often beneficial in reducing adverse cardiovascular events in higher-risk populations. Here, we present a patient who was found to have a 1 cm stalk-like lesion in the left atrial appendage on transesophageal echocardiogram prior to electrical cardioversion. Using multiple cardiac imaging modalities, including cardiac magnetic resonance imaging and computed tomography, the mass was eventually determined to be a chronic resolving thrombus. 

##plugins.themes.bootstrap3.article.details##

Keywords

atrial fibrillation, left atrial appendage thrombus, transesophageal echocardiogram, stalk lesion, anticoagulation

References
1. Kornej J, Börschel CS, Benjamin EJ, Schnabel RB. Epidemiology of Atrial Fibrillation in the 21st Century: Novel Methods and New Insights. Circ Res. 2020 Jun 19;127(1):4-20. doi: 10.1161/CIRCRESAHA.120.316340. PMID: 32716709; PMCID: PMC7577553.
2. Vanassche T, Lauw MN, Eikelboom JW, et al. Risk of ischaemic stroke according to pattern of atrial fibrillation: analysis of 6563 aspirin-treated patients in ACTIVE-A and AVERROES. Eur Heart J. 2015 Feb 1;36(5):281-7a. doi: 10.1093/eurheartj/ehu307. PMID: 25187524.
3. Wolf PA, Dawber TR, Thomas HE Jr, Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study. Neurology. 1978 Oct;28(10):973-7. doi: 10.1212/wnl.28.10.973. PMID: 570666.
4. Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020 Oct 1;383(14):1305-1316. doi: 10.1056/NEJMoa2019422. PMID: 32865375.
5. Tyebally S, Chen D, Bhattacharyya S, et al. Cardiac Tumors: JACC CardioOncology State-of-the-Art Review. JACC CardioOncol. 2020 Jun 16;2(2):293-311. doi: 10.1016/j.jaccao.2020.05.009. PMID: 34396236; PMCID: PMC8352246.
6. Lodhi AM, Nguyen T, Bianco C, Movahed A. Coumadin ridge: An incidental finding of a left atrial pseudotumor on transthoracic echocardiography. World J Clin Cases. 2015;3(9):831-4. doi: 10.12998/wjcc.v3.i9.831. PMID: 26380830; PMCID: PMC4568532.
7. Gupta S, Plein S, Greenwood JP. The Coumadin Ridge: An Important Example of a Left Atrial Pseudotumour demonstrated by Cardiovascular Magnetic Resonance Imaging. J Radiol Case Rep. 2009;3(9):1-5. doi: 10.3941/jrcr.v3i9.210. PMID: 22470681; PMCID: PMC3303338.
8. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. doi: 10.1093/eurheartj/ehaa612. Erratum in: Eur Heart J. 2021 Feb 1;42(5):507. Erratum in: Eur Heart J. 2021 Feb 1;42(5):546-547. Erratum in: Eur Heart J. 2021 Oct 21;42(40):4194. PMID: 32860505.
9. Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008 Jun 19;358(25):2667-77. doi: 10.1056/NEJMoa0708789. PMID: 18565859.
10. Zafeiropoulos S, Doundoulakis I, Bekiaridou A, et al. Rhythm vs Rate Control Strategy for Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials. JACC Clin Electrophysiol. 2024 Apr 15:S2405-500X(24)00187-7. doi: 10.1016/j.jacep.2024.03.006. PMID: 38727662.
11. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193
12. Lurie A, Wang J, Hinnegan KJ, et al. Prevalence of Left Atrial Thrombus in Anticoagulated Patients With Atrial Fibrillation. J Am Coll Cardiol. 2021 Jun 15;77(23):2875-2886. doi: 10.1016/j.jacc.2021.04.036. PMID: 34112315.
13. Merella P, Talanas G, Lorenzoni G, et al. Percutaneous Left Atrial Appendage Occlusion: What the Practising Physician Should Know. Eur Cardiol. 2023 Sep 28;18:e57. doi: 10.15420/ecr.2023.18. PMID: 37860701; PMCID: PMC10583154.
14. Akyüz Ş, Avcı II, Karabay CY, Genç D, Palice A. How to safely occlude left atrial appendage with a thrombus inside? Anatol J Cardiol. 2020 Jan;23(1):49-52. doi: 10.14744/AnatolJCardiol.2019.02222. PMID: 31911559; PMCID: PMC7141426.
15. Tarantini G, D'Amico G, Latib A, et al. Percutaneous left atrial appendage occlusion in patients with atrial fibrillation and left appendage thrombus: feasibility, safety and clinical efficacy. EuroIntervention. 2018 Jan 20;13(13):1595-1602. doi: 10.4244/EIJ-D-17-00777. PMID: 29086706.
16. Whitlock RP, Belley-Cote EP, Paparella D, et al. Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke. N Engl J Med. 2021 Jun 3;384(22):2081-2091. doi: 10.1056/NEJMoa2101897. PMID: 33999547.
How to Cite
Choi, J. ., Speirs, T. ., Bhatia, R. ., Sivalokanathan, S., & Craft, C. . (2024). Is it a thrombus or a tumor? An imaging dilemma for clinicians. Archive of Clinical Cases, 11(2), 37-40. https://doi.org/10.22551/2024.43.1102.10285
Section
Case Reports

How to Cite

Choi, J. ., Speirs, T. ., Bhatia, R. ., Sivalokanathan, S., & Craft, C. . (2024). Is it a thrombus or a tumor? An imaging dilemma for clinicians. Archive of Clinical Cases, 11(2), 37-40. https://doi.org/10.22551/2024.43.1102.10285