Thrombus on the Tricuspid Valve in a Patient With Primary Antiphospholipid Syndrome After Implantation of an Inferior Vena Cave Filter.

Abstract

ntiphospholipid syndrome (APS) is a combination of the clinical symptoms of arterial and venous thromboembolism and the presence of autoantibodies such as anticardiolipin 2 GPI antibody, the lupus anticoagulant and the antibodies responsible for the falsepositive serologic test result for syphilis. Primary APS (PAPS) is defined by the presence of these antibodies and thromboembolic phenomena without systemic lupus erythematosus (SLE) and other disease processes. Intracardiac thrombi have been reported, 1-7 but involvement of the tricuspid valve is extremely rare. 5 We report a case of PAPS with a lobulated thrombus on the tricuspid valve, which formed after implantation of a filter in the inferior vena cava (IVC) and resolved with fibrinolytic therapy. Case ReportA 62-year-old woman was admitted with progressive shortness of breath and tachypnea. The patient's medical history included a 15-year history of bronchial asthma, and a pulmonary embolism caused by a deep vein thrombus 5 years previously. At that time, computed tomography (CT) revealed a large thrombus in the main pulmonary artery, which dissolved with intravenous administration of tissue plasminogen activator. Although several perfusion -ventilation mismatch areas remained on the pulmonary perfusion scan after the therapy (segment 6 on the left, segment 8 on the right), she was discharged with no symptoms after the implantation of an IVC filter. Further evaluation during Circulation Journal Vol. 66, April 2002 that admission led to the diagnosis of PAPS with positivity for lupus anticoagulant. The anticardiolipin 2 GPI antibody level was less than 1.2 U/ml. Antinuclear antibodies were negative, and the activities of proteins C and S were normal, consistent with the diagnosis. She had no history of spontaneous abortion and had delivered normally with 3 pregnancies. After discharge, she was treated with warfarin with a target international normalized ratio (INR) of 2.0 at an outpatient clinic.One year later, she was admitted to examine her pulmonary pressure and right heart pressure, which were found to be in the normal range. A repeat pulmonary perfusion scan showed no change. She continued to be positive for lupus anticoagulant at the second admission. Since then, she has been followed at an outpatient clinic and managed with warfarin bronchodilator and warfarin. However, the warfarin therapy was discontinued 10 months prior to her third admission.On the third admission, she had an oxygen saturation of 89%, a respiratory rate of 28 breaths/min, and a 12-lead ECG that showed an inverted T wave in leads V1-3. Chest X-ray suggested dilatation of the right pulmonary artery. Laboratory tests revealed a white blood cell count of 12,500/mm 3 , hematocrit 41.7%, and platelet counts 124,000 /mm 3 . Transthoracic echocardiography revealed a 1.7×1.8 cm, lobulated, isoechoic, highly mobile mass on the septal leaflet of the tricuspid valve (Fig 1). The right atrium and ventricle were dilated and mild tricuspid regurgitation was detected, with an estimated pulmon...

Clinical Features of Acute Pulmonary Thromboembolism in Younger Patients.

“…12 On the other hand, insertion of IVC filters was not associated with a significant reduction in the 1-year incidence of rehospitalization for APTE. 13 A lobulated thrombus on the tricuspid valve of a patient with antiphospholipid antibody syndrome after implantation of IVC filter has been reported, 14 so the long-term effectiveness of IVC filters is controversial. Therefore, we deliberated whether to implant IVC filters, especially in the YG patients, and only the recurrent case and the patient with massive thrombosis in the IVC were implanted with a permanent IVC filter, concomitant with warfarin therapy.…”

A Rare Case of Large Organized Thrombus of the Tricuspid Valve in a Normal Heart

“…According to the aetiology, thrombosis of the tricuspid valve can be classified in four groups: caused by alterations of coagulation 6,7 (V Laiden factor, antiphospholipid antibody syndrome, etc.) incidental to deep venous thrombosis, 8–10 due to cardiac structural anomalies, 9 idiopathic forms in a structurally normal heart 11,12 and in the absence of a coagulation disorder.…”

Atrioventricular thrombus in a 14-year-old patient: a case report

“…Additionally, main risk of the patients consists in unpredictable pulmonary embolization[13]. Ebato et al[14], reported that the patients have presented with symptoms of cerebral embolism and pulmonary embolism. The traditional therapy for intracardiac thrombus in pediatric patients has been surgical thrombectomy.…”