M asses related to the tricuspid valve are infrequent pathologies of routine cardiology practice. Tumorous structures (especially fibroelastomas and carcinoid tumours) and vegetations due to right heart endocarditis are among the noted etiological factors. Isolated thrombi of the tricuspid valve are rare, and may yield confusion in differential diagnosis and therapy by mimicking vegetations or tumours.
CASE PRESENTATIONA 35-year-old woman with primary infertility undergoing a planned laparoscopic surgery was preoperatively evaluated because of a past atrial septal defect operation. She had atrial septal defect surgery 13 years previously and was asymptomatic at the time of writing. Gonadotropin-releasing hormone (GnRH) analogue therapy (leuprolide acetate 11.25 mg in depot form; repeated every three months) had been initiated for endometriosis. Pain and swelling had occurred in her right leg after the first injection of the GnRH analogue six months earlier. Doppler ultrasonography revealed deep venous thrombosis (DVT). Low-molecular-weight heparin, acetylsalicylic acid and nonsteroidal anti-inflammatory drugs were prescribed, and elevation of the leg was advised. Prophylactic anticoagulant treatment was not continued. Her mother had a history of recurrent pulmonary embolism (PE) and nephrolithiasis. The patient's physical examination was normal except for a loud second heart sound. She was in sinus rhythm, and a right bundle branch block was present on her electrocardiogram. A chest x-ray was normal. The left heart chambers were normal, the right chambers were dilated and the atrial septum was intact on echocardiography. In addition, a sessile echogenic image (10 mm × 10 mm in size but not disturbing valvular movement) was detected on the atrial side of the tricuspid valve and was confirmed by transesophageal echocardiography (Figure 1). Because of the DVT history, the mass was initially interpreted to be a thrombus, and anticoagulant treatment was initiated (1000 U/h heparin infusion after an intravenous bolus of 5000 U; the dose was determined by the partial thromboplastin time). Because echocardiography revealed regression of the size of the mass on the third day (Figure 2), heparin infusion was switched to low-molecular-weight heparin (enoxaparin 0.6 mL subcutaneously twice per day). Meanwhile, the patient suffered from mild dyspnea, requiring ventilation. Perfusion scintigraphy for probable PE appeared normal. Doppler ultrasonography of the lower legs was also normal. Clinical and laboratory investigations for underlying connective tissue disorders were normal (sedimentation rate was normal, and antinuclear and anti-DNA antibodies were negative). Anticardiolipin antibodies (immunoglobulin [Ig]G, IgM and IgA) for antiphospholipid syndrome were also negative. Homocysteine, fibrinogen, protein C, protein S and von Willebrand factor levels were within normal ranges, and activated protein C resistance was not detected. Finally, the previous DVT attacks and the present tricuspid valve thrombus were attributed to ...