A New-Onset Mass in the Right-Sided Atrium in a Child After Cardiac Surgery: Unravelling the Diagnosis

      A 2-year-old girl (weight: 9 kg, height: 82 cm) underwent an intracardiac repair. Preoperative transthoracic echocardiography revealed situs solitus, levocardia, left atrial isomerism, common atrium due to a large atrial septal defect, absent coronary sinus, 2 separate atrioventricular valves with a trivial left atrioventricular valve regurgitation due to a cleft in the anterior leaflet, and a dilated right ventricle with flattening of the interventricular septum due to volume overload (Fig. 1). Intraoperatively, it was found that the left hepatic vein was draining separately into the left-sided atrium. The atrial septation was done using an autologous pericardial patch, ensuring the left hepatic vein drainage was to the right-sided atrium. At the time of separation from cardiopulmonary bypass, midesophageal 4-chamber and bicaval transesophageal echocardiography views revealed a new, large, heterogeneous, dense, hypoechoic, nonpedunculated mass in the posteroinferior aspect of the right-sided atrium, which also was related to the anterior aspect of the inferior vena cava opening (Fig. 2; Videos 1 and 2). Sinus rhythm was present. Agitated saline injected into the femoral vein was seen in the atrium, indicating no obstruction to the inferior vena cava drainage by the mass (Fig. 3; Video 3). As the chest was still open, any presence of collection behind the heart was excluded. A color Doppler blood flow map showed the blood flow pattern through the body of the heterogeneous mass (Fig. 4; Video 4). A pulsed-wave Doppler signal demonstrated a systolic and diastolic flow pattern through the mass (Fig. 5). A closer inspection of the inferior vena cava area suggested the possible cause for the heterogeneous mass in the right atrium (Fig. 6). What is the diagnosis?
      Fig 1
      Fig 1Midesophageal 4-chamber view with color Doppler by transesophageal echocardiography showing the common atrium and the left atrioventricular valve regurgitation.
      Fig 2
      Fig 2Midesophageal 4-chamber and the bicaval views by transesophageal echocardiography showing a heterogeneous, dense, hypoechoic, nonpedunculated mass after separation from cardiopulmonary bypass.
      Fig 3
      Fig 3Midesophageal 4-chamber view by transesophageal echocardiography showing the unobstructed entry of agitated saline injected into the femoral vein.
      Fig 4
      Fig 4Midesophageal 4-chamber view with color Doppler by transesophageal echocardiography showing blood flow through the body of the heterogeneous mass.
      Fig 5
      Fig 5Midesophageal 4-chamber view with pulsed-wave Doppler signal analysis of the blood flow through the heterogeneous mass demonstrating systolic (S), diastolic (D), and atrial systolic (A) wave. A, atrial systolic; D, diastolic; S, systolic.
      Fig 6
      Fig 6Surgical image depicting the left hepatic vein entry in relation to the inferior vena cava and atriotomy closure suture line.


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