Right atrial mass in a post-COVID-19 patient

A 38-year-old lady presented to the hospital with shortness of breath and right sided chest pain. Symptoms were gradually progressive over few weeks. Her past history was significant with history of COVID-19 eight weeks prior. There were no remarkable clinical findings on examination.

Echocardiogram showed a right atrial mass of size 2.5 cm x 0.5 cm which was abutting the tricuspid valve. Patient had no other significant findings except moderate pulmonary artery hypertension on the echocardiography. She had no evidence of deep vein thrombosis in her lower limbs or pelvic veins and chest CT scan showed minimal post-COVID residual fibrotic bands. Her hematology work-up didn’t show any thrombotic predisposition.

She was started on anticoagulation with heparin initially and then warfarin. After four weeks of anticoagulation, there was no decrease in mass size and no significant improvement in her symptoms. It was decided to proceed with surgical excision in view of the above, suspicion of myxoma or organized thrombus and its risk of embolization.

Surgical Procedure

She underwent right atrial mass excision under cardiopulmonary bypass. Intraoperative transesophageal echocardiography confirmed the preoperative echocardiographic findings. Special attention had to be paid to careful cannulation of IVC without dislodging the mass as its attachment was close to the IVC-RA junction. The mass measured 2.0 x 2.0 cm. Part of the interatrial septum, that was excised with the mass, was repaired with pericardial patch.

Discussion

Multiple cases of right atrial mass following COVID-19 have been reported. An increased incidence of thrombotic events has been reported in patients with COVID-19 infection and pulmonary thromboembolism is one of the most important causes of clinical deterioration. We found a large thrombus in the right atrium after pneumonia caused by COVID-19, in a symptomatic patient in sinus rhythm with normal biventricular function. Prior reports have suggested improvement or prevention of deterioration in such patients with anticoagulation alone. We decided to proceed with surgical excision as the patient did not improve with four weeks of anti-coagulation.

Cardiac surgery in COVID-19 pandemic