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.