Mass in the Left Atrium Appendage - Case Report

Medical History

An 80-year-old woman sought medical attention for shortness of breath she had been experiencing for about 2 weeks. Her personal medical history included atrial fibrillation, breast cancer in remission (treated in the 1990s), COPD, a mechanical mitral valve, long-term anticoagulation with warfarin with good compliance, and a newly diagnosed lung tumor.

Diagnostic Process

Upon admission, she was hemodynamically stable, with only mild tachycardia (110/min). Oxygen saturation was > 90%, with wheezing heard over both lungs (in the context of COPD). Complete blood count and basic biochemical tests were normal. INR was 4.9 (therapeutic target for this patient was 3.0-3.5).

CT angiography ruled out pulmonary embolism but revealed a solid mass in the left atrium extending into the appendage. Transesophageal echocardiography clarified the findings – the mass measured 6.1 x 2.6 cm, filling the left atrial appendage and extending through the left atrium to the mitral valve region. It was suspected to be a thrombus, but the possibility of a tumor was not excluded.

Treatment

Cardiac surgeons did not recommend open surgery due to comorbidities. Anticoagulant therapy was initiated – the patient received heparin infusions for 2 days, then was switched to enoxaparin.

Results and Conclusion

Her shortness of breath significantly improved within 2 weeks of starting therapy. A follow-up echocardiogram after 2 weeks showed the mass had reduced to about half its original size, indicating its thrombotic nature. The oncologist initiated outpatient chemotherapy without discontinuing enoxaparin.

The development of a thrombus in the left atrium during warfarin therapy was likely associated with the presence of the lung tumor. As this case report shows, low-molecular-weight heparin can be a beneficial option for anticoagulant therapy in these patients.

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Source: Shabbir M. A., Saad Shaukat M. H., Castellano A., Mookherjee S. Massive left atrial thrombus found incidentally in a cancer patient on chronic warfarin therapy treated with enoxaparin. Eur Heart J Case Rep 2020 Apr 25; 4 (3): 1-2, doi: 10.1093/ehjcr/ytaa100.