Cardiovascular Surgery and Interventions
2016, Vol 3, Num 3 Page(s): 077-079
A left atrial thrombus forming an antibioma: a rare entity | |
DOI: 10.5606/e-cvsi.2016.583 | |
Trushar Gajjar, Nageswar Rao, Neelam Desai | |
Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, CTVS Department, Prasanthigram, Andhra Pradesh, India | |
Keywords: Antibioma; Lutembacher’s syndrome; mitral valve replacement; thrombus left atrial appendage | |
An antibioma is defined as a hard edematous swelling containing sterile pus following treatment of an abscess with long-term
antibiotherapy. Abscess of the heart, as any abscess elsewhere in the body, develops in two principal ways: (i) by dissemination from a
distant infectious focus (ii) by direct extension of an infectious process located in the heart itself. Even the fresh blood clot in the heart
may become infected. Herein, we report the first case of the left atrial thrombus forming an antibioma following the Lutembacher's repair. |
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Antibioma, which is a rare anomaly of the heart,
is defined as a hard edematous swelling containing
sterile pus following treatment of an abscess with
long-term antibiotherapy. In the literature, a left atrial
(LA) antibioma has never been reported. Herein, we
present an unusual case of the LA thrombus forming
an antibioma following the Lutembacher’s repair. |
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CASE PRESANTATION
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A 28-year-old female was admitted with complaints
of dyspnea on exertion. She was in the New York
Heart Association Class II (NYHA II) for four years.
Through a detailed examination, she was diagnosed
with Lutembacher’s syndrome. A two-dimensional
echocardiography revealed ostium secundum atrial
septal defect and severe mitral stenosis. There was no
history of pulmonary tuberculosis or thrombus in the
left atrium or appendage. Ostium secundum atrial
septal defect was closed with an autologous-untreated
pericardial patch and mitral valve was replaced with
a 29-tilting disc mechanical prosthetic heart valve.
Surgery was uneventful. On postoperative Day 2, the
patient developed high-grade fever (38 °C). Blood culture
showed a heavy growth of Streptococcus which was treated
according to Streptococcus-sensitive antibiotics. She was
extubated in the fifth postoperative day. The patient
was on an anticoagulant with international normalized
ratio (INR) set at 2.5 to 3.0. In the ninth postoperative
day, transthoracic echocardiography showed a large
LA thrombus (Figure 1), despite oral anticoagulants and target INR. She was, then, put on heparin;
however, repeated echocardiography did not show any
improvement. The patient developed tachypnea and
chest X-ray and computed tomography (CT) scan
showed patchy confluent areas of consolidation in both
the lungs, more dense in the lower lobes. Thoracic CT
also showed mosaic perfusion along with the areas
of ground-glass changes in both the lungs with an
organized thrombus in the posterior part of the LA
(Figure 2) measuring 4x3 cm in size without a thrombus
in the LA appendage. The patient was scheduled for
LA clot removal. Intraoperatively, there was a large,
4x3x3 cm, well-defined globular mass with very thin
glistening covering of the left atrium just beneath the
right inferior pulmonary vein away from the prosthetic
valve and the patch (Figure 3). During manipulation,
the mass ruptured and turbid brown-colored fluid
came out. The wall of the mass was excised and pus
was drained. The pus was sent for culture, which did
not grow any organism initially. The LA was cleaned
with normal saline and vancomycin. Following the
redo surgery, the patient required tracheostomy due to
prolonged intubation and she continued to have spikes
of fever with blood culture growing Candida albicans.
On Day 118 days of the intensive care unit (ICU) stay,
the patient developed multi-organ failure secondary to fungal septicemia. Histopathologica report suggested
an infected thrombus and fluid culture was reported as
the growth of Stenotrophomonas maltophilia. |
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Antibioma of the heart is a rare occurrence which has
not yet been documented in the literature. It is defined as a hard edematous swelling containing sterile pus
following the treatment of an abscess with longterm
antibiotherapy.[3] Abscess of the heart, as any
abscess elsewhere in the body, develops due to (i) the
dissemination from a distant infectious focus, (ii) the
direct extension of an infectious process located in
the heart itself,[1] or (iii) fresh blood clot in the heart
becoming infected, as in our case.[1-3] Prosthetic valve endocarditis can lead to abscess formation; however,
it is usually limited to the annulus and may infect the
newly formed clot in the vicinity.[2] In our case, we
initially suspected of prosthetic valve endocarditis;
however, prosthetic valve appeared normal and a new
thrombus formed at the posterior wall of left atrium,
near the right inferior pulmonary vein. The main cause
probably would be (i) damage to the endothelium and
raw exposed muscle with persistent atrial fibrillation
would have become the source for the clot[3] or (ii) the
atrial septal defect closure with a pericardial patch
would have left suture or raw pericardial tissue at the
lower most end of the patch, which might have formed
the clot which became infected over a period of time
due to prolonged ICU stay and hospital-acquired
infection, or (iii) possibility of very low cannulation
of inferior vena cava and deep reinforcement of the
suture would form the pocket where the blood became
stagnated and formed a thrombus at the lower end of
the interatrial septum, in particular. This was probably
the cause in our case. In such cases, diagnosis can be
obtained by echocardiography and antibioma can be
suspected, if the clot is in unusual position, as in our
case, and does not respond to intravenous heparin.
Computed tomography offers the exact location and
the content of the mass. Surgical evacuation thorough normal saline wash with antibiotics is the primary
treatment of choice. However, the postoperative course
remains stormy and outcome may be dismal. In conclusion, antibioma of the left atrium is a very rare occurrence with no published literature to date. Therefore, we believe that early recognition and aggressive management may yield satisfactory outcomes.
Declaration of conflicting interests
Funding |
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