Right Atrial Thrombus and Pulmonary Embolism in a Patient with Constrictive Pericarditis

Madhu Shukla; Jagdish Chander Mohan

doi:10.4103/jiae.jiae_5_23

INTERESTING CASE REPORT

Year : 2023 | Volume : 7 | Issue : 2 | Page : 189-192

Right Atrial Thrombus and Pulmonary Embolism in a Patient with Constrictive Pericarditis

Madhu Shukla, Jagdish Chander Mohan
Department of Cardiology, Institute of Heart and vascular Diseases, Jaipur Golden Hospital, New Delhi, India

Date of Submission	18-Jan-2023
Date of Decision	14-Feb-2023
Date of Acceptance	15-Feb-2023
Date of Web Publication	05-Apr-2023

Correspondence Address:
Jagdish Chander Mohan
A51, Hauz Khas, New Delhi - 110 016
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_5_23

Abstract

A 27-year-old male was admitted with dyspnea of sudden onset and was initially diagnosed to have acute pulmonary embolism, bilateral pleural effusion, and mild pericardial effusion. Detailed echocardiographic examination revealed echocardiographic features of constrictive pericarditis (CP), marked spontaneous contrast in inferior vena cava, and a right atrial thrombus. The patient had bilateral lung consolidation and pleural effusion presumably of tubercular origin. Intracardiac thrombi are rare in patients with CP and may impact prognosis and management strategy.

Keywords: Constrictive pericarditis, pulmonary embolism, right atrial thrombus

How to cite this article:
Shukla M, Mohan JC. Right Atrial Thrombus and Pulmonary Embolism in a Patient with Constrictive Pericarditis. J Indian Acad Echocardiogr Cardiovasc Imaging 2023;7:189-92

How to cite this URL:
Shukla M, Mohan JC. Right Atrial Thrombus and Pulmonary Embolism in a Patient with Constrictive Pericarditis. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2023 [cited 2023 Sep 27];7:189-92. Available from: https://jiaecho.org/text.asp?2023/7/2/189/373606

Introduction

Constrictive pericarditis (CP) is characterized by stasis due to low blood flow velocities in the systemic venous system and high intracardiac diastolic pressures. This may result in the development of spontaneous echo contrast, clot formation, and thromboembolism. Intracardiac thrombi, mostly in the right atrium, have been reported in about a dozen patients with CP since 1984.^{[1],[2],[3],[4],[5],[6],[7]} This report describes a young man who presented with acute pulmonary embolism and was diagnosed to have CP, right atrial thrombus, and dense spontaneous contrast in the inferior vena cava (IVC).

Case Report

This 27-year-old man had an intermittent fever, progressive dyspnea, cough, and weight loss for the past 6 months. He presented with acute dyspnea and cardiovascular collapse to another hospital in the pulmonology department and was treated as a case of pulmonary thromboembolism. After discharge, he sought a review in our institution. Physical examination showed a lean and thin cachexic young man with heart rate of 115 bpm, abnormal heart sounds, and pulse paradoxus; blood pressure of 88/60 mmHg; Kussmaul respiration; and obvious distension of jugular vein, severe bilateral leg edema, abdominal distension, and hepatomegaly. A 12-lead electrocardiogram showed low voltage graph, sinus tachycardia, and nonspecific ST-T changes. A chest skiagram revealed bilateral moderate pleural effusion, a patch of consolidation in the right upper zone, thickened right-sided interlobar fissure, and mild cardiomegaly [Figure 1]. Laboratory findings included hemoglobin 9 gm/dL, hypoproteinemia with albumin 2.8 gm/dL, hypokalemia with serum potassium 2.9 mmol/L, and serum bilirubin level of 1.6 mg/dL with raised liver enzymes. The right pleural fluid showed an albumin level of 1.6 gm/dL, a few lymphocytes and an adenosine deaminase level of 6 IU/L. The echocardiography revealed dilated IVC (27 mm) and hepatic veins with dense spontaneous echo contrast that slowly hurdled toward the right atrium [Figure 2] and [Video 1], isoechoic pericardial thickening and a right atrial mobile dense rounded mass of 1.2 cm × 1.2 cm adjacent to the opening of IVC [Figure 3] and [Video 2], respirophasic mitral and tricuspid early diastolic flow velocities with marked ventricular septal shift [Figure 4], [Figure 5] and [Video 2], “annulus paradoxus” and “annulus reversus” on tissue Doppler imaging of the mitral annulus [Figure 6], and “strain inversus” on acoustic speckle tracking of the left ventricle [Figure 7]. In addition to bilateral pleural effusion, other observations included reduced left ventricular ejection fraction (34%), respirophasic atrial septal shift, persistent diastolic flow reversal in the hepatic veins, mild tricuspid regurgitation, no pulmonary regurgitation, and pulmonary valve acceleration time of 97 ms, and “longitudinal strain inversus” of the right ventricle [Figure 8] and [Video 3].

Figure 1: Posteroanterior chest skiagram showing bilateral pleural effusion and right upper zone consolidation

Click here to view

Figure 2: Subcostal transthoracic long-axis view of the IVC showing dense spontaneous contrast (a). (b) Persistent nonphasic diastolic flow reversal in hepatic vein. IVC: Inferior vena cava

Click here to view

Figure 3: Transthoracic echocardiographic apical views showing dense rounded thrombus (arrows) at the junction of inferior vena cava and the right atrium. LA: Left atrium, LV: Left ventricle, RA: Right atrium, RV: Right ventricle

Click here to view

Figure 4: Transthoracic echocardiographic four-chamber views in diastole during expiration (a) and during inspiration (b). Note respirophasic septal shift (arrow). Also note pericardial thickening all around the ventricles. LA: Left atrium, LV: Left ventricle, RA: Right atrium, RV: Right ventricle

Click here to view

Figure 5: Views similar to Figure 4 showing reciprocal biventricular volume changes typical of constrictive pericarditis during different phases of respiration. Light blue: right ventricle, brown: left ventricle

Click here to view

Figure 6: Phenomenon of annulus reversus. Tissue Doppler velocities at medial and lateral ends of the mitral annulus showing paradoxically high medial e' velocity (15 cm/s [a]) compared to lateral e' velocity (8 cm/s [b]), which is typical of constrictive pericarditis

Click here to view

Figure 7: Acoustic speckle tracking in apical four-chamber view showing “strain inversus” of the left ventricle. Septal longitudinal strain (−10%) is several folds higher than lateral longitudinal strain (−1.8%). The green line represents the endocardial border automatically marked by the speckle tracking software

Click here to view

Figure 8: Acoustic speckle tracking of the right ventricle showing “strain inversus”. Average longitudinal strain of the right ventricular-free wall is −1.2%, whereas mean of all six segments is −3.4%. The green line represents the endocardial border automatically marked by the speckle tracking software. RV4CSL: Right ventricular four-chamber longitudinal strain, RVFWLS: Right ventricular free wall longitudinal strain

Click here to view

[Additional file 1]

Video 1: Dense spontaneous contrast in the inferior vena cava.

[Additional file 2]

Video 2: Apical four-chamber view showing right atrial thrombus, respirophasic septal shift, thickened pericardium, and nearly immobile lateral wall of the left ventricle.

[Additional file 3]

Video 3: Apical four-chamber view showing right ventricular strain reversus.

Contrast-enhanced chest computed tomography (CT) scan showed bilayered pericardial thickening with mild pericardial effusion [Figure 9], patchy bilateral consolidation with moderate bilateral pleural effusion, and a hypodense rounded mass in the right atrium. Multiple filling defects were seen in the segmental branches of the right pulmonary artery with some left segmental branches showing abrupt cutoff [Figure 10]. In view of the echocardiographic and CT appearance in the presence of dense spontaneous contrast, the right atrial mass was presumed to be a thrombus but with no histological confirmation. The patient has been put on presumptive antitubercular therapy and rivaroxaban. A pericardiectomy is planned after 3 months.

Figure 9: Chest computed tomography scan shows pericardial thickening with pericardial effusion (white arrows) and patchy bilateral consolidation with moderate bilateral pleural effusion. Yellow arrow points to the thrombus in the right atrium. LA: Left atrium, LV: Left ventricle, PE: Pleural effusion, RA: Right atrium, RV: Right ventricle

Click here to view

Figure 10: Computed tomographic chest scan in axial view showing thrombi in segmental branches of the right pulmonary artery (white arrows) and bilateral patchy consolidation (yellow arrows). AO: Aorta, LPA: Left pulmonary artery, PE: Pleural effusion, RPA: Right pulmonary artery, SVC: Superior vena cava

Click here to view

Discussion

The main pathogenetic causes of thrombi include hemostasis and endothelial injury. In CP, impairment of filling of the ventricles during diastole causes hemostasis in the venous systems. Dense spontaneous echo contrast and venous thrombosis have been reported in CP.^[8],[9] There are scattered case reports mentioning right atrial thrombi in the presence of CP, either found incidentally or causing tricuspid valve obstruction or change in intraoperative strategy.^{[1],[2],[3],[4],[5],[6],[7]} However, presentation with acute pulmonary embolism has not been reported. We presume that our patient had active pulmonary tuberculosis and exudative pericarditis that resulted in CP with typical echocardiographic features. The thrombus probably occurred in situ based on its shape and location. The source of multiple showers of pulmonary artery emboli was also probably the right atrium or the IVC. Intracardiac thrombi and pulmonary embolism in the presence of CP can complicate hemodynamics, prognosis, surgical approach, and even postoperative need for anticoagulation.

Conclusion

Intracardiac thrombi may be associated with CP and may influence prognosis and therapeutic approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Akiyama K, Nakae S, Imamura E, Endo M, Hayashi H. A case of right atrial thrombus associated with constrictive pericarditis. Rinsho Kyobu Geka 1984;4:607-12.
2.	Nishimura T, Misawa T, Park YD, Uehara T, Hayashida K, Hayashi M. Visualization of right atrial thrombus associated with constrictive pericarditis by indium-111 oxine platelet imaging. J Nucl Med 1987;28:1344-7.
3.	Katagiri M, Tanabe Y, Takahashi M, Kasuya S. Right atrial thrombosis: Association with constrictive pericarditis. Ann Thorac Surg 1990;49:145-6.
4.	Ozhan H, Okçun B, Akdemir R. Constrictive pericarditis associated with right atrial and major venous thrombosis. Acta Cardiol 2004;59:435-7.
5.	Priestley KA, Wallwork J, Schofield PM. Right atrial thrombus in constrictive pericarditis. Int J Cardiol 1992;37:256-8.
6.	Gourav KP, Damodaran S, Bhat I, Negi S, Revanth M, Upadhayaa V, et al. Perioperative concerns and management of patients with right atrial thrombus in chronic constrictive pericarditis undergoing pericardiectomy: A case series. J Perioper Echocardiogr 2019;7:6-11.
7.	Kumar R, Raja J, Rawat S, Srivastava A, Thingnam SK. Chronic constrictive pericarditis complicated with huge right atrial thrombus in a child with abdominal tuberculosis: A rare life-threatening condition. J Surg Case Rep 2019;2019:rjz295.
8.	Pahade A, Tewari P. Major vessel venous thrombosis in patients of posttubercular chronic constrictive pericarditis undergoing pericardectomy: A rare scenario. Ann Card Anaesth 2017;20:348-50. [PUBMED] [Full text]
9.	Majumder B, Chatterjee PK, Chatterjee S, Sudeep KN. A rare case of dense spontaneous echo contrast within inferior vena cava. J Cardiovasc Echogr 2018;28:204-6.