The differential diagnosis of right atrial mass includes vegetation, tumor, and thrombus. The most frequent echocardiographic findings in antiphospholipid syndrome are either valve vegetations or thickening of the valve leaflets. Although tricuspid vegetations can mimic a right atrial mass, they are typically attached to the valve leaflet. These findings are more frequent than that of intracardiac thrombus.
The most common primary cardiac tumor is the myxoma. Fifteen percent of atrial myxomas arise in the right atrium, and they are usually attached to the interatrial septum. Although in our patient the attachment site was the free wall of the right atrium, atrial myxoma was a possible diagnosis.
Right atrial thrombi can develop in several situations. First, they may arise from venous emboli that have become entrapped in the right heart. These thrombi often appear as mobile, irregular masses that float freely in the right atrium. Our patient had a highly mobile and friable mass, but it was not floating freely in the right atrium. In addition, a right atrial thrombus may develop in situ under low-flow conditions. These thrombi are typically immobile, and this too was not the hemodynamic situation of our patient.
The risk of intracardiac thrombosis or thromboembolism is increased in patients who have SLE and who either show positive test results for lupus anticoagulant activity or have medium or high levels of anticardiolipin antibodies.2
A retrospective study of 637 patients3 found that venous thrombosis with PE was more frequent in persons who had lupus anticoagulant activity; while coronary, cerebrovascular, and peripheral arterial events were more likely in individuals who had elevated levels of IgG or IgM anticardiolipin antibodies.
The presence of calcium in our patient's mass helped to narrow the diagnosis. The calcification of an atrialmyxoma appears to occur more frequently when the tumor is in the right atrium4; however, the calcification of thrombi in all cardiac chambers has been reported.5–8
Patients who have SLE and secondary antiphospholipid syndrome can develop intracardiac thrombi. In our patient, preoperative investigations could not differentiate such a thrombus from a myxoma; consequently, the diagnosis was made postoperatively.
It remains unknown whether prolonged heparin administration, thrombolysis, high-intensity anticoagulation with warfarin, intravenous administration of rituximab (an anti-CD20 monoclonal antibody), or surgical excision is the best therapeutic approach. Regardless, the great size of this mass and its polypoid and mobile appearance on 2-dimensional echocardiography—which seemed to place our patient at high risk for PE—led us to choose surgical excision. Moreover, the pathologic features of an organized thrombosis with early calcified deposits, which could constitute the nucleus for further thrombus deposition, further supported the surgical approach.
Recurrent events are common in antiphospholipid syndrome. Most observers have noted that initial arterial thrombosis tends to be followed by an arterial event, and initial venous thrombosis, by a venous event.9–11 The factors that determine whether the affected circulation will be venous or arterial are not known.
Among patients who have antiphospholipid syndrome, the recurrence rate of thrombotic events varies. A prospective study of 360 patients (326 with lupus anticoagulant and 185 with anticardiolipin antibodies) determined that 34 (9%) experienced a recurrent thrombotic event during a median follow-up period of approximately 4 years. Some of these events occurred despite oral anticoagulation therapy,10 as was the case with our patient during the immediate postoperative period.
In other series, higher recurrence rates have resulted. One prospective study of 81 patients who had antiphospholipid antibodies found that 31% experienced recurrent ischemic strokes; patients with high titers of anticardiolipin antibodies (>100 GPL units) and patients with intracardiac thrombus had a shorter time until recurrence.12,13