N AUNG1, J SPIRO2, I GILFILLAN3, H KULKARNI1
1Department of Nephrology and Cardiology, Royal Perth Hospital, Perth, Western Australia; 2Department of Cardiology, Royal Perth Hospital,Perth, Western Australia; 3Department of Cardio-thoracic Surgery, Fiona Stanley Hospital, Murdoch, Western Australia
Background: Right atrial (RA) thrombus complicated by pulmonary embolism in patient with recurrence of FSGS in an allograft is a rare and potentially life-threatening complication. Hickman catheter, plasmapheresis and haemoconcentration post-plasmapheresis were considered contributory.
Case-Report: A 22-years-female with recurrence of FSGS, 30-months-post-renal-transplant on standard triple immunosuppression. Plasmapheresis via an Internal Jugular central venous catheter (CVC) was pursued with good initial response (Proteinuria decline from 9000 to 650mg/day) and maintained on thrice weekly regimen. Episodes of tachycardia during plasmapheresis and poor blood flows needing rewiring of CVC were noticed about 2 weeks prior to her presentation with large PE. 2D-echo showed Right atrial mass 2.6cm x 2.9cm, attached to the right atrial free wall/distal part of the Hickman line, moderate pericardial effusion and pulmonary hypertension. Systemic anticoagulation over 6 weeks showed no shrinkage of the clot, and surgical thrombectomy was pursued with cardiopulmonary bypass to avoid embolization.
Intraoperative findings of large RA thrombus attached to the distal end of CVC with extension to IVC warranted removal of patch of right atrial wall. CVC was removed after 48 hours post-surgery. Histopathology confirmed organised thrombus with few areas of calcification.
Risks of medical v/s surgical management in a young girl, risks of sudden death from massive thromboembolism, failed medical management despite anti-coagulation led to surgical option.
Nephrotic syndrome, haemoconcentration post-plasmapheresis and CVC were established risk factors. Thrombolysis was not considered due to risks of embolism.
Conclusions: RA thrombus is rare and should be considered in any patient with CVC and high risk of thrombosis. Surgical option in skilled hands may remain a preferred option in suitable patients. Routine anticoagulation or regular screening echo may be useful for prevention.