Atypical imaging presentation of a massive intracavitary cardiac thrombus: A case report and brief review of the literature

Figures

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  Fig. 1. Chest Radiograph was initially reported as no acute process. However, on subsequent review, a calcified retrocardiac mass was seen (Yellow arrow) (Color version of figure is available online)

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  Fig. 2. CT chest PE protocol demonstrated a large intracavitary heterogeneous irregular calcified mass extending into the right atrium, across the tricuspid valve, and into the right ventricle and pulmonary outflow tract. Additionally, small to moderate pericardial effusion was noted, with reflux of contrast in the collateral veins, suggestive of restrictive cardiac dysfunction.

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  Fig. 3. Transthoracic echocardiogram during evaluation in the emergency department confirmed the presence of a small pericardial effusion and showed significant clot burden and possible intracavitary right ventricular mass which was incompletely characterized.

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  Fig. 4. CT heart morphology revealed a heterogeneous irregular calcified mass extending into the right atrium, across the tricuspid valve. This mass had characteristics suggestive of an organized chronic thrombus, as webs of thrombus were extending throughout the right atrium and almost completely occluding the distal superior vena cava. A small pericardial effusion is also present.

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  Fig. 5. CT heart morphology, coronal reconstruction revealed a heterogeneous irregular calcified mass extending into the right ventricle and pulmonary outflow tract.

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  Fig. 6. Cardiac MRI (A): Long T1 short axis demonstrated diffuse hypointense signal characteristics of this mass; (B): On first pass post contrast imaging, it was difficult to differentiate tumor enhancement from intervening blood pool. (C): Late Gadolinium Enhancement PSIR revealed no contrast enhancement. Moderate sized pericardial effusion was again noted.

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  Fig. 7. Hematoxylin and eosin (H&E) sections (B) & (E)) show the lines of Zahn which are layers of red blood cells alternating with platelets and fibrin. The lines of Zahn are characteristic of thrombus formation in the context of pulsatile blood flow. (A): Organizing thrombus with calcification (400x) (B): Organizing thrombus with fibrovascular tissue (100x). (C): Organizing thrombus with fibrous tissue and scattered hemosiderin-laden macrophages (100x). ) (D): Organizing thrombus and fibrous tissue with extensive calcifications (20x) (E): Organizing thrombus and fibrous tissue with extensive calcifications (40x). (F): Organizing thrombus, fibrous tissue, calcifications and scattered hemosiderin-laden macrophages (100x).