Off-pump right atrial thrombectomy for heparin-induced thrombocytopenia with thrombosis

Comparison of inflow occlusion on the beating heart with cardiopulmonary bypass in the extraction of a mass lesion or a foreign body from the right heart

OBJECTIVE

Two basic surgical techniques exist in the extraction of a mass lesion or a foreign body from the right atrium and/or the right ventricle. These are inflow occlusion of the right heart and with assistance of the cardiopulmonary bypass (CPB). In this study, these two methods were compared.

METHODS

Between May 2001 and April 2010, 15 patients were operated upon for the extraction of a mass lesion or a foreign body from the right heart. Seven patients were operated upon using venous inflow occlusion technique, whereas eight patients were operated upon using CPB. These two groups were evaluated and compared in terms of clinical parameters.

RESULTS

Intracardiac masses or foreign bodies were completely removed by using both methods. Patients who were operated upon using inflow occlusion on beating heart (IOBH) developed no postoperative complication, whereas two patients who were operated upon with CPB developed complications, postoperatively. Moreover, duration of hospital stay, duration of intensive care unit (ICU) stay, and intubation time were significantly lower in the IOBH group when compared with the CPB group. In the CPB group, the amount of blood transfused was significantly higher.

CONCLUSIONS

In suitable patient groups, the IOBH technique could be safely performed by experienced centers.

Right atrial thrombus masquerading as intracardiac cyst: a case report

Intracardiac cystic lesions are rare. Hydatid disease, blood cysts and bronchogenic cysts in various chambers of the heart have been reported. Right atrial thrombus presenting as a cystic lesion on echocardiogram has not been reported. We describe a patient with mitral regurgitation in atrial fibrillation with a right atrial cyst, which was found to be a cavitating thrombus.

[Heparin-induced thrombocytopenia]

Hemorrhage is the most common and best-recognized complication of heparin treatment. However, a potentially more dangerous complication is the development of heparin-induced thrombocytopenia (HIT). All patients exposed to heparin, irrespective of the dose and route of administration, are at risk of developing HIT. It is due to the formation of antibodies against the heparin-platelet factor 4 complex, which cause secondary activation of platelets, coagulation and, finally, increased thrombin production. The main symptom is the sudden onset of thrombocytopenia involving a drop in the platelet count to less than 50% of the basal level, with or without the appearance of thrombotic complications some 5 to 14 days after the start of heparin therapy. Heparin-induced thrombocytopenia can be detected early in patients receiving heparin by monitoring the platelet count. Demonstration of heparin-dependent platelet activation using an antigen or functional assay confirms the clinical diagnosis. Once the diagnosis of HIT has been confirmed serologically or there is a high level of suspicion of HIT, heparin must be suspended and treatment with an alternative anticoagulant should be considered. This review contains a discussion of the diagnosis and treatment of this syndrome.

Eleven-year experience in diagnosis and surgical therapy of right atrial masses

BACKGROUND

Tumors arising from the right atrium are quite rare, and require special care during differential diagnosis for their management. A review of surgical experience with right atrial tumors in 11 patients from our institution has been presented in this article.

METHODS

Eleven cases, operated for a tumor mass in the right atrium in our institution between January 1993 and December 2004, were retrospectively reviewed for their clinical presentation, diagnostic workup, method of surgical procedure, and histopathologic findings. Electrocardiogram, transthoracic, and transesophageal echocardiography, computerized tomography, and nuclear magnetic resonance imaging were available for all patients during the diagnostic evaluation. Surgical procedure notes, photos, and file recordings were reviewed when available. The surgeons were also interviewed when necessary.

RESULTS

Right atrial tumors were diagnosed in 11 patients (6 males and 5 females). The average age of the patients was 34 +/- 11 years (ranging between 21 and 65 years). The histopathological examination of the surgically removed specimen revealed a benign tumor in eight patients (73%), and a malignant process in three (23%). In eight patients with a benign tumor, atrial myxoma was the leading cause in half of the cases. Hydatid cyst (n = 2), lipoma (n = 1), and right atrial thrombus (n = 1) were detected in the remaining four patients. One patient died of heart failure after surgery. The diameters of the excised masses were 2 +/- 0.5 cm versus 7 +/- 1 cm.

CONCLUSIONS

Tumors of the right atrium are rarely seen, and necessitate a unique attention during the process of diagnosis and surgical treatment. We present our surgical experience of 11 patients with right atrial mass. The differentiation of the right atrial tumors with the diagnostic tools before surgery, the determination of the spreading, and the structural properties of the mass may designate surgical approach and prognosis.