Primary antiphospholipid syndrome and cardiac involvement. Description of a clinical case of right atrial thrombosis

Antiphospholipid syndrome is a well-defined clinical and serological entity characterized by venous and arterial thrombosis, recurrent abortion and thrombocytopenia. The immunological feature shows the presence of anticardiolipin antibodies and lupus anticoagulant. Cardiac involvement includes pericardial effusion, myocardial dysfunction, valvular disease, coronary artery occlusion. The literature reports only a few cases of intracardiac thrombosis associated with primary antiphospholipid syndrome. Here we describe a case of a 54 year-old woman with thrombocytopenia and history of recurrent abortions. When she was 51 she presented a left deep iliac venous thrombosis, followed by recurrent pulmonary embolism; a caval filter was placed in the inferior vena cava. Transthoracic and transoesophageal echocardiogram showed 3 masses in the right atrium: the first one was connected with the atrial wall, hyperechogenic and extending to the right ventricle in diastole: th second was connected with the interatrial septum and less echogenic; the third was in connection with septum-tricuspid valve junction and it was floating in the atrium. The immunological feature showed the presence of lupus anticoagulant and antiphospholipid antibodies; the histological examination of the masses, surgically removed, proved they were thrombi coated by endothelial cells. The case reported is very uncommon and offers the opportunity to emphasize the difficulty of diagnostic differentiation of intracardiac masses using echocardiographic imaging: thrombotic masses may present similar characteristics of seat, morphology and echogenicity of other cardiac masses. For these reasons it can be useful to look for antiphospholipid antibodies and lupus anticoagulant in such clinical conditions.