Abstract
Image(s)
Transesophageal echocardiography, cardiac computed tomography, and histopathology.
Case Summary
A 50-year-old man with previous cryptogenic stroke and patent foramen ovale closure was found to have a large mobile mass on the left atrial side of the occluder approximately 33 months after implantation. Surgical extraction was performed because of embolic risk. Pathology demonstrated benign myocardium mixed with adipose tissue, supporting atypical endothelialization rather than thrombus or infection.
Take-Home Messages
Late masses on patent foramen ovale occluder devices may mimic thrombus or vegetation. Multimodality imaging, surgical inspection, and pathology are essential for diagnosis.
Key Words: complication, computed tomography, echocardiography, occluder, 3-dimensional imaging, thrombus
Graphical Abstract
A 50-year-old man with previous cryptogenic stroke underwent patent foramen ovale (PFO) closure with a 25-mm septal occluder. Approximately 33 months later, he presented with shoulder pain and mildly elevated troponin. Computed tomography angiography was obtained during evaluation for acute coronary syndrome and pulmonary embolism. This revealed an incidental intracardiac mass attached to the left atrial side of the occluder; the mass was not ultimately felt to explain the presenting symptoms.
Transesophageal echocardiography demonstrated a large mobile pedunculated mass arising from the left atrial side of the occluder (Figure 1A, Video 1). Cardiac computed tomography showed an irregular low-density mass measuring 2.2 × 1.4 cm with attenuation of approximately 60 to 80 HU, favoring device-related thrombus (Figure 1B). Three-dimensional transesophageal echocardiography further characterized the mass-device relationship and demonstrated attachment to the occluder (Figure 1C, Video 2). Transthoracic and transesophageal echocardiography showed no residual interatrial shunt. Blood cultures showed no growth, and there was no strong clinical evidence of infection.
Figure 1.
Multimodality Evaluation of an LA Mass After Patent Foramen Ovale Closure
(A) Two-dimensional transesophageal echocardiography demonstrating a large mobile pedunculated mass on the left atrial side of the patent foramen ovale occluder. (B) Cardiac computed tomography demonstrating an irregular low-density mass attached to the left atrial side of the occluder. (C) Three-dimensional transesophageal echocardiography demonstrating the relationship between the mass and the occluder. (D) Histopathology demonstrating benign myocardium mixed with adipose tissue. The arrow in (A) and (C) refer to the mass on the device in the LA. Arrow in (B) points at the device. Asterisk in (D) refers to the interposed adipose tissue in the myocardium. LA = left atrium; LV = left ventricle; RA = right atrium.
The differential diagnosis included device-related thrombus, infective vegetation, cardiac tumor, and abnormal tissue ingrowth. Because of the size and mobility of the mass and concern for systemic embolization, the patient was treated with systemic unfractionated heparin for approximately 48 hours during the index hospitalization and referred for surgical management. He underwent open surgical extraction of the occluder with repair of the resulting atrial septal defect. Intraoperatively, the previously placed closure device was excised using sharp dissection, and an attached mass that appeared grossly consistent with fibrosed clot-like material was removed intact from the left atrium. The resulting large atrial septal defect was repaired with a bovine pericardial patch.
Histopathology demonstrated benign myocardium mixed with adipose tissue. There was no evidence of thrombus, malignancy, vegetation, or organisms. These findings supported atypical device endothelialization rather than thrombus, vegetation, or tumor (Figure 1D). Anticoagulation was not continued after pathology did not confirm thrombus, and the patient was discharged with outpatient follow-up.
PFO closure is indicated to reduce the risk of paradoxical emboli in adults between the ages of 18 and 60 with a previous PFO-associated stroke.1 The safety and long-term outcomes associated with PFO device closure have been previously published.2 Known complications associated with these devices include embolization, cardiac perforation, infection, and thrombosis.1 This case highlights a rare late complication of PFO occlusion in which abnormal endothelialization may mimic device-related thrombus or vegetation. Multimodality imaging helps define the lesion, but final diagnosis may require surgical and histopathologic correlation. Recognition of this entity is important because management differs substantially from anticoagulation alone.
Funding Support and Author Disclosures
HCA Healthcare Disclaimer: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
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Appendix
For the supplemental videos and a video summarizing the case, please see the online version of this paper.
Appendix
Two-Dimensional Transesophageal Echocardiography Demonstrating Mobility of the Left Atrial-Sided Mass Attached to the Patent Foramen Ovale Occluder
Three-Dimensional Transesophageal Echocardiography Demonstrating the Attachment of the Mass to the Left Atrial Side of the Occluder
Video Summary
Clinical presentation and multimodality evaluation of a late left atrial-sided mass attached to a patent foramen ovale occluder, including cardiac computed tomography, 2-dimensional and 3-dimensional transesophageal echocardiography, and histopathologic findings supporting atypical device endothelialization.
References
- 1.Giblett J.P., Williams L.K., Kyranis S., Shapiro L.M., Calvert P.A. Patent foramen ovale closure: state of the art. Interv Cardiol. 2020;15:e15. doi: 10.15420/icr.2019.27. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Krumsdorf U., Ostermayer S., Billinger K., et al. Incidence and clinical course of thrombus formation on atrial septal defect and patient foramen ovale closure devices in 1,000 consecutive patients. J Am Coll Cardiol. 2004;43(2):302–309. doi: 10.1016/j.jacc.2003.10.030. [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Two-Dimensional Transesophageal Echocardiography Demonstrating Mobility of the Left Atrial-Sided Mass Attached to the Patent Foramen Ovale Occluder
Three-Dimensional Transesophageal Echocardiography Demonstrating the Attachment of the Mass to the Left Atrial Side of the Occluder
Video Summary
Clinical presentation and multimodality evaluation of a late left atrial-sided mass attached to a patent foramen ovale occluder, including cardiac computed tomography, 2-dimensional and 3-dimensional transesophageal echocardiography, and histopathologic findings supporting atypical device endothelialization.