In January 2021, a 21-year-old Libyan female presented to a tertiary care center in Tripoli, Libya for evaluation and management of a right atrial and ventricular cardiac mass/thrombus. It was also associated with left inferior lobar pulmonary embolism and thrombocytopenia. In the first exam, the patient was dyspneic at rest, tachypneic, bilateral decreased air entry with no added sound, and abdominal examination showed a distended abdomen with no tenderness or organomegaly. The patient’s heart rate was 111 bpm, blood pressure was 100/80 mmHg, O2 saturation was 95%, and the temperature was 38.2°C. trans-thoracic echocardiogram (TTE) revealed a large thrombus/mass occupying the right atrium and right ventricle that measured 8 × 6 cm. CT pulmonary angiography revealed a left inferior lobar pulmonary embolism. Abdominal ultrasound showed only minimal ascites with mild hepatomegaly. After being admitted to the Cardiac Care Unit (CCU), clinical assessment excludes the presence of thrombosis in the deep venous system, but no duplex ultrasound has been performed to confirm that.
In medical history, the patient had complained of breathlessness, dry cough, myalgia, and arthralgia associated with intermittent fever reaching up to 40⁰Cْ four months before. The patient was suspected to have contracted SARS-COV-2 infection at that time before her presentation with a large thrombus on the right side of the heart. Unfortunately, no reliable investigations were taken to confirm that she was infected. However, at the time of admission, serological tests of IgG and IgM antibodies of SARS-COV-2 were positive with a negative nasal swab.
Two days after admission to the CCU, the patient’s hemoglobin and platelet count dropped significantly to 9.5 g/dl and 85.5×10 mm, respectively, and the basal numbers were hemoglobin of 10.43 g/dl and a platelet count of 111.3×10 mm. Furthermore, the platelet count continued to drop until it reached 21.6× 10 mm within the first week; also, liver function tests (LFT) revealed high readings. During that time, 4 units of platelets were administered with no significant improvement in her thrombocytopenia. While being there in the CCU for approximately 11 days, they hoped to treat her medically. The patient was on rivaroxaban with heparin infusion under close monitoring.
In the initial assessment, surgical intervention was decided, and the plan was to perform a thrombectomy. Trans-esophageal echocardiography (TEE) was performed before surgery, which showed a huge atrioventricular thrombus measured 8 × 6 × 4 CM (Fig. 1). Furthermore, TEE represents a cauliflower mass in the right atrium with a pedicle in the middle, which raised suspicion of myxoma covered with a thrombus (Fig. 2). In the operation, the arterial and venous cannulation of the cardiopulmonary bypass (CPB), an additional pulmonary clamp was applied to prevent small thrombi from escaping to the lungs and causing any further pulmonary embolism. Yet, entering the right atrium, a large thrombus occupied the right atrium and right ventricle, and the thrombus extended up to the inferior vena cava (Fig. 3a,b ). However, we encountered difficulties in removing what was suspected to be a thrombus since the mass was connected to the wall of the right atrium with a pedicle, and a specimen was sent for further histopathological assessment. Additionally, extended suction of the inferior vena cava was performed to ensure that no thrombi remained. Tricuspid valve ring annuloplasty was also performed, as the mechanical effect led to valve insufficiency.
Overall, the operation went smoothly with no complications. She was transferred to the ICU, and her stay was uneventful. During the next days, the patient had significant clinical improvement. The histopathology study revealed a core of atrial myxomatous tissue with the presence of a thrombus surrounding it. Finally, the patient was discharged after 1-week post-operatively in a good general condition under a prophylactic dose of warfarin. After 6 months, TTE revealed the absence of any residual thrombosis, and no recurrence of myxoma was noticed.