Biatrial masses in a heart transplant patient.

A 55-year-old man presented with hypotension, altered mental status, and atrial fibrillation of 4 hours' duration. He had undergone orthotopic heart transplantation 20 years earlier with a standard anastomosis, and he had been on hemodialysis for the past 3 months. The patient had no history of coagulopathies, and he had not recently traveled or undergone surgery. Blood cultures were negative for pathogenic bacteria. Transesophageal echocardiography (Fig. 1A) showed a complex, multilobular, mobile mass attached to the anterior surface inside the right atrium, along the transplant suture line. The echocardiogram also revealed a minimally mobile, circumscribed, ovoid mass attached to the posterior wall inside the left atrium. There was no patent foramen ovale. The patient opted for conservative therapy and was treated with anticoagulation and antibiotics. Four days later, he experienced cardiac arrest and regained consciousness after cardiopulmonary resuscitation. Transthoracic echocardiography did not show the left atrial mass (Fig. 1B). Three hours later, the patient sustained another cardiac arrest and died. Autopsy confirmed a right atrial thrombus (Fig. 1C), no thrombus or mass in the left atrium, and recent multiple infarcts in the spleen (Fig. 1D), kidneys, pancreas, and gallbladder. Fig. 1 A) Transesophageal echocardiography (4-chamber view) shows a complex, multilobular, mobile mass in the right atrium along the transplant suture line (arrowhead), and a minimally mobile, circumscribed ovoid mass in the left atrium (arrow). B) Transthoracic ...