2 ︱ CASE PRESENTATION
A 49-year-old male underwent transcatheter ASD closure one year ago and
was continuously treated with aspirin for long-term antiplatelet
therapy. Six months ago, the patient was hospitalized for dry cough and
pleural effusion and was unfortunately misdiagnosed as pneumonia. One
week after the previous admission, the patient was admitted to a
high-level hospital for hemoptysis and right-limb weakness and was
diagnosed with pulmonary embolism. After antithrombotic and symptomatic
treatment, he recovered and was discharged home with long-term
rivaroxaban therapy.
At the latest admission, the patient presented with dizziness and
pectoralgia and was diagnosed with acute cerebral infarction and
pulmonary embolism. Physical examination revealed 3/5 strength in the
right-limb without any other central nervous system abnormalities.
Electrocardiogram (ECG) was normal sinus rhythm. Blood tests showed a
normal complete blood count and normal coagulation function.
Brain computed tomography (CT) manifested as post-infarction of cerebral
lacunar with no significant abnormalities (FIGURE 1A). Pulmonary CT
angiography presented embolism in the distal of the right pulmonary
artery and its branches (FIGURE 1B-C). Transthoracic echocardiography
(TTE) showed a 13×9 mm hypoechoic
mass attached to the left-atrial side of the device, which was suspected
to be either neoplasm or thrombus
(FIGURE 1D-F). There was no shunt at the atrial level and left
ventricular contraction was normal. Then transesophageal echocardiogram
(TEE) was recommended to further examine this mass.
Three-dimensional
TEE revealed fan-like vegetation (21×16 mm) attached to the left-atrial
side of the device and short rod-like vegetation (8×6 mm) attached to
the right-atrial side (FIGURE 2, VIDEO 1-3).
The patient was treated with low-molecular heparin anticoagulation and
aspirin antiplatelet under ECG and coagulation (APTT ratio) monitoring,
followed by device removal and atrial defect repair under
cardiopulmonary bypass. Following the operation, double-sided
vegetations were found on the device, which were confirmed to be
thrombosis by laboratory tests. TTE re-examination at 5th day after
operation showed the atrial septum was continuous and complete without
shunts and thrombus. The patient was fully recovered and discharged home
with long-term anticoagulation therapy.