The use of combined transoesophageal echocardiography and fluroscopy in the biopsy of a right atrial mass

Transoesophageal echocardiography has increasing application to the diagnosis of a wide range of cardiac disorders (Roelandt & Sutherland, 1988). Recently, simultaneous ultrasound imaging of the heart by the oesophageal route has been used during certain interventional cardiac procedures (Cryan et al, 1988; Neumann et al, 1988). We report a case in which transoesophageal echocardiography was used in combination with fluroscopy to facilitate the biopsy of a right atrial mass. A 14-year-old Asian boy presented with a short history of malaise, cough and haemoptysis associated with intermittent pleuritic chest pain. Physical examination revealed signs of bilateral pleural effusions and right-sided heart failure, with jugular venous pressure elevated 6 cm above the suprasternal notch and mild peripheral oedema. His pulse rate was 90 beats/ min and his blood pressure was 140/80 mmHg with no paradox. The pleural effusions were confirmed radiologically, but the chest radiograph and electrocardiogram (ECG) yielded no further diagnostic information. Pulmonary infarcts were suspected and, in the search for a source of emboli, praecordial cardiac ultrasound revealed distortion of the tricuspid valve annulus. This was further delineated by transoesophageal echocardiography which clearly showed a mass in the posterolateralwall of the right atrium causing displacement of the tricuspid valve (Fig. 1). The patient's family were unwilling to allow cardiac surgery to be performed and so a biopsy of the mass was chosen as the next diagnostic approach. A Cordis bioptome was introduced via the right femoral vein and tip positioned at the junction of the inferior vena cava and the right atrium using radiological screening.