Intraoperative detection of a right atrial mass during holmium: YAG laser lithotripsy: A fatal and rare complication: A case report

RATIONALE: Holmium:YAG laser lithotripsy is widely used for the treatment of urinary tract stones and is generally considered safe. However, cardiovascular complications such as intracardiac masses are exceedingly rare and potentially fatal. This report presents a case in which an unexpected right atrial mass was detected intraoperatively during laser lithotripsy under general anesthesia using real-time transthoracic echocardiography. PATIENT CONCERNS: A 54-year-old woman with right-sided hydronephrosis and ureteral calculi was admitted for elective holmium:YAG laser lithotripsy. Preoperative evaluations revealed elevated urinary leukocytes and C-reactive protein, with no evidence of cardiovascular abnormalities. DIAGNOSES: During the procedure, the patient developed sudden hypotension, tachycardia, and hypoxia. Emergency bedside transthoracic echocardiography revealed a large hypoechoic mass in the right atrium obstructing blood flow. Although the exact nature of the mass could not be confirmed, findings were highly suggestive of an acute thromboembolic process. INTERVENTIONS: Immediate thrombolytic therapy with urokinase was administered, accompanied by continuous ultrasound monitoring. The mass showed evidence of fragmentation and partial resolution. Despite transient improvement in hemodynamics, the patient experienced cardiac arrest several hours later and could not be resuscitated. OUTCOMES: No autopsy was performed. Based on clinical deterioration, imaging progression, and absence of other identifiable causes, a fatal cardiac event, potentially related to embolization of an intracardiac mass, was considered the most probable cause of death. LESSONS: This case highlights the importance of preoperative and intraoperative cardiovascular monitoring in urologic patients, particularly those at risk for infection-related hypercoagulability. Bedside transthoracic echocardiography facilitates the early detection of newly developed or evolving acute intracardiac events, and in future cases, pulsed-wave tissue Doppler imaging may be considered to further assess thrombus mobility and embolic risk. For future high-risk patients, preoperative evaluation, including thromboelastography or other laboratory tests, and timely or prophylactic antibiotic administration may help identify occult hypercoagulability and reduce infection-related thrombotic risk. Postoperatively, low-dose heparin can be cautiously considered under close laboratory supervision to manage thrombotic risk.