We report the case of a male patient with a history of recent pulmonary embolism and peripherally inserted central catheter who presented with severe dyspnea. He was found to have a large mass on the tricuspid valve, and definitive diagnosis remained elusive until surgical intervention. The thrombotic potential of central venous catheterization should not be overlooked in patients presenting with dyspnea and appropriate history of central access.
Peripherally inserted central catheters (PICCs) have become a mainstay for inpatient and outpatient medicine treatments with over 5 million placed annually in the United States.1 There are various complications associated with PICCs, one being deep-vein thrombosis involving the upper extremities. PICCs have a thrombosis incidence between 10% and 38%. Risk factors for this include catheter diameter, with larger catheters having a higher risk, catheter malpositioning, malignancy, hereditary or acquired thrombophilia, multiple insertion attempts, prior deep vein thrombosis, recent surgery, and left-sided catheters.2-6 Complications of upper-extremity deep vein thrombosis (UEDVT) include pulmonary embolism (6% for upper extremities vs 15% to 32% for lower extremities), recurrent UEDVT at 12 months (2% to 5% for upper extremities vs 10% for lower extremities), and postthrombotic syndrome (5% for upper extremities vs up to 56% for lower extremities).6 The following case highlights the importance of maintaining a high index of suspicion of PICC-associated complications in the appropriate population.
A 32-year-old man with a history of right hand osteomyelitis and tobacco use presented with 3 weeks of significant fatigue and worsening dyspnea on exertion. Previously active in sports, he could now only walk 10 feet without severe dyspnea and associated symptoms of pre-syncope. He also reported that he was recently told he had a new diagnosis of heart murmur, but no further investigation had been undertaken. Osteomyelitis due to orthopedic hardware complications was diagnosed 9 months prior to this presentation, and he was treated with intravenous antibiotics via PICC for a total of 4 weeks. He reported entry site complications and leaking around the catheter, requiring removal and replacement for a total of 3 catheter insertions. At the end of his 4-week antibiotic regimen, he developed shortness of breath and was subsequently diagnosed with a pulmonary embolism at another facility. The PICC was removed at the time of diagnosis, and no echocardiogram was performed. He was treated with rivaroxaban 15 mg twice daily for 21 days, followed by 20 mg daily for a total treatment duration of 90 days. After completing treatment with rivaroxaban, he was asymptomatic and reported returning to his prior level of functioning for approximately 3 months. He then began to develop worsening fatigue and dyspnea on exertion that prompted his presentation at our facility, at which time he was referred for an outpatient pulmonology and cardiology assessment. Underlying pulmonary pathology was quickly ruled out. He underwent transthoracic echocardiogram at the cardiologist’s office and was immediately referred to the hospital for admission.
Computed tomography of the chest revealed a large right-sided cardiac mass (Figure 1). Transesophageal and repeat transthoracic echocardiograms confirmed this finding, as well as revealing mild tricuspid regurgitation and severe tricuspid stenosis secondary to the mass (Figures 2 and 3). The mass measured approximately 4.9 cm × 2.3 cm with a stalk coming from the right anterior wall and a ball-valve effect appreciated during the examination. No other significant valvular abnormalities were seen. No structural abnormalities were visualized. Based on this study, it was felt that the diagnosis was most consistent with a right atrial myxoma. Left heart catheterization revealed no significant obstructive coronary artery disease.
The patient was taken to the operating room the next day for median sternotomy. The mass was adherent to the posterior and septal leaflets of the tricuspid valve (Figure 4).
Successful removal was achieved by peeling the mass from the leaflets without causing visible injury (Figure 5). Grossly, the mass was firm and rigid. Histopathologic findings revealed a large organizing clot and adhering granulation tissue (Figure 6). Blood and tissue cultures were negative, and hypercoagulable studies revealed no abnormalities. The patient was discharged home 5 days postoperatively in stable condition.
Native tricuspid valve thrombus is quite uncommon, particularly in an individual without structural heart disease or antiphospholipid syndrome (APLS). It is frequently mistaken for infective endocarditis or tumor. The majority of case reports involve individuals with structural heart disease such as ventricular septal defect and coagulative disorders, especially APLS.7-9 Our patient presented with a structurally normal heart and no evidence of hypercoagulable disorder or malignancy.
The patient described a history of likely catheter malposition, requiring 3 separate devices to complete his antibiotic course. Intravenous catheters can cause endothelial disruption and trauma, leading to thrombosis.3 Catheter malposition is also associated with increased incidence of thrombosis and right heart thromboemboli (RHTE).10 RHTEs are associated with pulmonary embolism in approximately 4% to 6% of cases.10,11
In this case, we suspect that the thrombus originated from a PICC-induced thrombus of the upper extremity. Thrombi became entrapped on the tricuspid valve. For unknown reasons, the natural fibrinolytic system failed and a massive organized thrombus developed.
Management strategy of right heart thrombus remains controversial. Treatment options include systemic and catheter-directed thrombolysis, anticoagulants, and surgical removal.7,10,12,13 Definitive treatment is often surgical, as attempts to thrombolyse can lead to embolization of the clot. Novel techniques utilizing large catheter aspiration (ie, Angiovac, Angiodynamics, Latham, NY) can also be potentially useful. Davies et al also reported a case of percutaneous retrieval and sequestration using an inferior vena cava filter.13
In this case of a large, organized thrombus adherent to the tricuspid leaflets, percutaneous approaches would likely not be successful and pose too great a risk of embolization given the size and location of the thrombus. Surgical excision should remain the definitive treatment for thrombi of this nature.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Smith and Golino report no conflicts of interest regarding the content herein. Dr Mathews discloses that he is a reviewer for VDM.
Manuscript submitted March 1, 2018; accepted April 10, 2018.
Address for correspondence: S. Jay Mathews, MD, MS, Manatee Memorial Hospital, Bradentown, Florida. Email:firstname.lastname@example.org
1. Trerotola SO, Stavropolous SW, Mondschein JI, et al. Triple-lumen peripherally inserted central catheter in patients in the critical care unit: prospective evaluation. Radiology. 2010;256(1):312-320.
2. Flinterman LE, Van Der Meer FJM, Rosendaal FR, Doggen CJM. Current perspective of venous thrombosis in the upper extremity. J Thromb Haemost. 2008;6(8):1262-1266.
3. Jones D, Wismayer K, Bozas G, Palmer J, Elliott M, Maraveyas A. The risk of venous thromboembolism associated with peripherally inserted central catheters in ambulant cancer patients. Thromb J. 2017;15:25.
4. Mustafa S, Stein PD, Patel KC, Otten TR, Holmes R, Silbergleit A. Upper extremity deep venous thrombosis. Chest. 2003;123(6):1953-1956.
5. Joffe HV, Kucher N, Tapson VF, Goldhaber SZ, Deep Vein Thrombis (DVT) FREE Steering Committee. Upper-extremity deep vein thrombosis: A prospective registry of 592 patients. Circulation. 2004;110(12):1605-1611.
6. Kucher N. Clinical practice: deep-vein thrombosis of the upper extremities. N Engl J Med. 2011;364(9):861-869.
7. Gunduz Y, Ucar A, Vatan MB, Keser N. Tricuspid valve thrombus causing acute pulmonary embolism. BMJ Case Reports. 2013;pii: 10.1136/bcr-2012-006995.
8. Mukhopadhyay S, Suryavanshi S, Yusuf J, et al. Isolated thrombus producing tricuspid stenosis: an unusual presentation in primary antiphospholipid syndrome. Indian Heart J. 2004;56(1):61-63.
9. Konishi H, Fukuda M, Kato M, Misawa Y, Fuse K. Organized thrombus of the tricuspid valve mimicking valvular tumor. Ann Thorac Surg. 2001;71(6):2022-2024.
10. Burns KE, McLaren A. Catheter-related right atrial thrombus and pulmonary embolism: a case report and systematic review of the literature. Can Respir J. 2009;16(5):163-165.
11. Shah P, Vasudev R, Pullatt R, Shamoon F. Peripherally inserted central catheter-induced right atrium thrombosis and superior vena cava dissection. J Vasc Access. 2017;22(1):20-21.
12. Saxena P, Mejia R, Tam RKW. A rare presentation of tricuspid valve thrombus in a normal heart. Ann Thorac Surg. 2005;80:1498-1500.
13. Davies RP, Harding J, Hassam R. Percutaneous retrieval of a right atrioventricular embolus. Cardiovasc Intervent Radiol. 1998;21(5):433-435.