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JAMA Cardiology Clinical Challenge
December 30, 2020

Urgent Need for Diagnosis of a Rapidly Growing Right Atrial Mass

Author Affiliations
  • 1Department of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
  • 2Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
  • 3Feinberg School of Medicine, Division of Cardiology, Department of Medicine, Northwestern University, Chicago
JAMA Cardiol. 2021;6(3):350-351. doi:10.1001/jamacardio.2020.6107

A middle-aged man with no relevant medical history presented to the emergency department with progressive shortness of breath, a productive cough, fatigue, weight loss, and night sweats for several months. A few days prior to presentation, he had developed palpitations, chest discomfort, and lower-extremity swelling. He denied taking any medications or recent international travel. In the emergency department, he had a normal blood pressure with an irregular heart rate at 104 beats per minute. On examination, he had bilateral basilar crackles and traces of lower extremity edema. An electrocardiogram revealed that he was experiencing atrial flutter. A computed tomographic angiogram showed an acute pulmonary embolism, multiple bilateral pulmonary nodules, mediastinal lymphadenopathy, and a right atrial mass. He then underwent a transthoracic echocardiogram with 2-dimensional speckle-tracking strain, which revealed a 4.5 × 3.6 × 3.1-cm pedunculated right atrial mass attached to the interatrial septum near the fossa ovalis (Figure 1A; Video). Left ventricular function was noted to be reduced and cardiac mechanics by 2-dimensional speckle-tracking strain were markedly abnormal, suggesting a more diffuse myocardial process (Figure 1B).

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