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A Seedless Grape in the Heart

Originally publishedhttps://doi.org/10.1161/CIRCULATIONAHA.115.015997Circulation. 2015;132:e189–e190

    A 65-year-old woman was admitted with shortness of breath and chest pain. A computed tomographic angiogram of the chest performed for suspected pulmonary embolism showed a filling defect in the left atrium, concerning for a tumor or thrombus (Figure, A). Transesophageal echocardiography revealed a large mobile mass in the left atrium attached to the interatrial septum with a very short pedicle (Figure, B and Movie I in the online-only Data Supplement). The patient had a history of surgical patent foramen ovale closure with a Prolene suture, mitral valve repair, and saphenous vein bypass graft to the right coronary artery a year and a half previously. Her antithrombotic therapy after surgery was aspirin. She had no history of atrial fibrillation, arterial or venous thromboembolic disease, recent infections, or intravascular or cardiac devices. Considering the high risk of embolism, surgical removal of the mass was planned. A coronary angiogram before the operation showed an occluded vein graft and progression of left anterior descending artery disease. On surgical exploration, the mass was loosely attached to the interatrial septum and left atrial trabeculae and did not involve the mitral valve or the mitral repair ring (Figure, C). The mass was reddish tan, roughly oval, and 2.5×2×1.5 cm and had a rubbery consistency (Figure, D). Histopathological analysis was consistent with an organized blood clot (Figure, E and F). A radial artery bypass graft to the posterior descending artery and an in situ left internal mammary artery to left anterior descending artery graft were also performed. The patient had an uneventful recovery and was discharged to home on aspirin and clopidogrel.

    A small incidence of thrombus formation on patent foramen ovale closure devices has been reported, with a higher risk in patients with postprocedural atrial fibrillation and persistent atrial septal aneurysm.13 There are no known reports of thrombus formation at or near the site of surgical closure of a patent foramen ovale in short- or long-term follow-up.4,5 The underlying pathophysiology of thrombus formation near the surgical closure site of patent foramen ovale in the present case remains unknown.

    Figure.

    Figure. A, Computed tomography scan shows a filling defect in the left atrium. B, Modified transesophageal echocardiogram shows a large, round mass in the left atrium attached to the interatrial septum. C, The left atrial mass as seen in the left atrium at surgery. D, The mass after surgical excision from the left atrium. E, Hematoxylin and eosin stain of the left atrial mass at ×10 magnification, consistent with thrombus components (fibrin, platelets, and red cells) F, Hematoxylin and eosin stain of mass at ×20 magnification of thrombus showing the lines of Zahn, alternating pale platelet– and fibrin-rich layers (thin arrow) and darker red cell–rich layers (thick arrow).

    Acknowledgments

    We thank Dr Amira Gohara, Department of Pathology, University of Toledo Medical Center, for her valuable input.

    Footnotes

    The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.115.015997/-/DC1.

    Correspondence to George V. Moukarbel, MD, Division of Cardiovascular Medicine, Department of Medicine, University of Toledo Medical Center, 3000 Arlington Ave, MS No. 1118, Dowling Hall, Toledo, OH 43614. E-mail

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