Right Atrial Thrombus and Pulmonary Embolism One Year After Ventricular Septal Defect Patch Repair: A Case Report

Right Atrial Thrombus and Pulmonary Embolism One Year After Ventricular Septal Defect Patch Repair: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Right Atrial Thrombus and Pulmonary Embolism One Year After Ventricular Septal Defect Patch Repair: A Case Report Osama Abouelfetouh Elshaer, Mahmoud Gomaa, Mohamed Elsayed Abdelfattah, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9440854/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 17 You are reading this latest preprint version Abstract Background: Right heart thrombi are rare but life-threatening, with particularly high mortality when accompanied by pulmonary embolism (PE). Cardiac surgery may predispose to in-situ thrombus formation via suture lines or patch material, yet thromboembolic risk and preventive strategies following Ventricular Septal Defect (VSD) repair remain unclear. Here, we report a case of a young patient with a massive right atrial (RA) thrombus with PE one year after VSD repair in the absence of any known hypercoagulable state. Case presentation: A 17-year-old male with a history of surgical VSD repair one year earlier, who was not taking any antithrombotic therapy prior to presentation, presented with acute dyspnea, tachycardia, and severe hypoxia. Transthoracic echocardiography revealed a large, freely mobile RA mass. Subsequent CT pulmonary angiography and cardiac magnetic resonance confirmed a massive right pulmonary artery embolus and characterized the RA mass as an intracardiac thrombus. Because of clinical deterioration despite therapeutic anticoagulation, he underwent a successful urgent cardiac surgery with RA mass excision and pulmonary embolectomy. Postoperative histopathology confirmed the mass to be a thrombus. Conclusions: Our case highlights a rare late RA thrombus with PE one year after surgical VSD repair, requiring urgent surgery. Further research is needed to clarify post–VSD closure surveillance and thromboprophylaxis strategies. Cardiac Surgery Case Report Intracardiac Mass Pulmonary Embolism Ventricular Septal Defect Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Right heart thrombi (RHT) are a rare but life-threatening clinical entity, classically categorized as either “thrombi-in-transit” originating from the deep venous system or mural thrombi forming in situ in the setting of structural or congenital heart disease or intracardiac foreign material [1]. Mortality is high, particularly when complicated by pulmonary embolism (PE) [2]. Cardiac surgery can create a thrombogenic substrate through atriotomy suture lines, prosthetic or patch material, and altered right-sided flow, allowing in-situ RHT formation that may subsequently present as PE. However, data on long-term thromboembolic (TE) outcomes specifically after surgical Ventricular Septal Defect (VSD) closure remain limited [3]. Additionally, post–VSD repair surveillance and TE prophylaxis for RHT remain controversial and are typically individualized on a case-by-case basis [4]. In this report, we describe a highly unusual case of a massive right atrial (RA) thrombus with PE occurring in a young patient one year after VSD repair, in the absence of any known hypercoagulable state. Case presentation A 17-year-old male with a history of congenital perimembranous VSD diagnosed at birth (measuring 6 mm) presented with acute-onset shortness of breath, markedly decreased exercise tolerance, and palpitations that began two days prior to evaluation. He had been regularly followed up until undergoing surgical VSD GORE-TEX® patch (expanded PTFE) closure with concomitant tricuspid valve repair using ring annuloplasty approximately 12 months before the current presentation. During this follow-up, his postoperative course was uncomplicated, and baseline preoperative and early postoperative transthoracic echocardiography (TTE) demonstrated successful repair without evidence of intracardiac masses or thrombi. He presented initially to the cardiology outpatient clinic in a state of hemodynamic compromise, with a blood pressure of 90/60 mmHg, heart rate of 135 beats/min, respiratory rate of 35 breaths/min, and oxygen saturation of 80% on room air. On physical examination, he appeared distressed and tachypneic. Neck exam showed mild jugular venous distension and there was no lower limb edema. Electrocardiography (ECG) showed sinus tachycardia. Urgent transthoracic echocardiography (TTE) identified a well-defined, lobular, freely mobile RA mass measuring 22 x 14 mm and attached to the crista terminalis ( Fig. 1 ) . Given the severity of hypoxemia and concern for TE pathology, the patient was admitted immediately to the cardiac care unit (CCU) and therapeutic anticoagulation was initiated (Enoxaparin 60 mg SC q12h). CT pulmonary angiography was done, and -in addition to the RA mass- it revealed a large central filling defect in the right main pulmonary artery, with multiple additional filling defects in the right-sided branches ( Fig. 2 ) . Given evidence of massive PE with hemodynamic compromise, therapeutic anticoagulation with enoxaparin was continued, and the patient was kept in the CCU and managed with supportive measures. To further characterize the RA mass and distinguish thrombus from alternative etiologies, cardiac magnetic resonance (CMR) imaging was performed, which showed the mass displaying iso-intense signal in T1 and iso- to hyper-intense signal in T2 and no significant contrast uptake at perfusion, supporting the diagnosis of an intracardiac thrombus over a tumor or vegetation ( Fig. 3 ). A comprehensive thrombophilia evaluation was negative. Additionally, there was no prior personal history of venous TE, no family history of thrombophilia, and no indwelling central venous catheter. Despite anticoagulation, the patient experienced clinical deterioration over the subsequent 2 days, with worsening dyspnea and increasing distress. Given the progressive clinical trajectory and imaging findings, decision was reached by a multidisciplinary team of cardiologists and cardiac surgeons to proceed with urgent cardiac surgery. Notably, the subcostal IVC long-axis TTE view incidentally revealed a 19 x 15 mm hepatic lesion consistent with a hemangioma (Supplementary Figure) . Although there were no clinical or laboratory features of active bleeding, we deferred systemic thrombolysis for PE management and surgical decision was made given the patient’s further clinical deterioration, the concomitant RA mass, and the anticipated need for urgent surgical intervention. Four days from admission, the patient underwent successful excision of the RA mass and pulmonary embolectomy. Surgery achieved complete removal of an organized RA thrombus and multiple PE ( Fig. 4 ) . Histopathology confirmed the excised mass nature to be a thrombus. Postoperatively, the patient was successfully weaned from mechanical ventilation, extubated, and achieved hemodynamic stabilization, and he remains hemodynamically stable at present. Discussion It is well recognized that repair of adult congenital heart defects can be complicated by TE events [5]. Late TE complications after either device closure or surgical patch septal defects closure have been previously reported in the literature [6–8]. However, all published reports were following ASD closure. Long-term complications following VSD repair were explored by Hofmeyr et al., who suggested that reduced RV size and diastolic dysfunction may be associated with right heart failure and arrhythmias without mentioning a significant risk for RHT [9]. However, in a nationwide case-control study, individuals with VSD had a significantly higher risk of venous thromboembolism (VTE) compared with matched controls, suggesting that VSD is associated with increased TE risk even when repair status is not specified [10]. Despite this, RA thrombosis following VSD repair in the absence of any known hypercoagulable state or indwelling catheters appears extremely rare and, to our knowledge, has not been previously reported; we believe this is the first report of this complication. Looking into literature, we found some reports that could explain the course of our challenging case. Since most VSD repairs are commonly performed via a transatrial approach to access the VSD through the TV, a post-atriotomy scar / irregular endocardial surface can promote local thrombosis leading to a late RA thrombus arising from the right-atrial incision site [11]. As we previously mentioned, it’s worth noting that our patient’s VSD closure surgery one year before presentation was done concomitantly with tricuspid valve repair. Additionally, post-repair atrial thrombi have been described in relation to surgical closure sites, with foreign material and suture lines considered potential thrombogenic triggers [12, 13]. This is supported by histopathologic findings showing focal regions of endothelialization along patch material in explanted specimens [12]. In cases of large, mobile RA thrombi with PE and clinical deterioration, a timely aggressive approach including surgical thrombectomy and embolectomy is often pursued, as observational data suggest that thrombolysis and surgical thrombectomy are associated with better survival in these patients [14]. However, TE prophylaxis strategies following VSD surgical repair remain unclear. The American College of Cardiology (ACC) clinical practice algorithm notes that surgically repaired VSDs can be followed every 2–5 years, and an echocardiogram is not routinely needed unless there is residual VSD or a clinical change [15]. A narrative review of postoperative anticoagulation in congenital heart disease notes that ASD and VSD repairs have historically not required routine anticoagulation, and when used after septal defect repair, it is typically reserved for higher-risk situations rather than isolated defects [4]. Ongoing research is warranted to better define optimal postoperative follow-up imaging and TE prophylaxis strategies for this population. Conclusions Our case represents an extremely rare presentation of late right atrial thrombus with pulmonary embolism one year after surgical VSD patch closure and tricuspid valve repair, occurring in the absence of an identified hypercoagulable state and requiring timely surgical intervention. Further studies are warranted to better define postoperative surveillance strategies and thromboprophylaxis for comparable postoperative scenarios. Abbreviations VSD: Ventricular Septal Defect ASD: Atrial Septal Defect PE: Pulmonary Embolism RA: Right Atrium RHT: Right Heart Thrombi TE: Thromboembolism VTE: Venous Thromboembolism TV: Tricuspid Valve TTE: Transthoracic Echocardiography TEE: Transesophageal Echocardiography CCU: Cardiac Care Unit CMR: Cardiac Magnetic Resonance ECG: Electrocardiography CTPA: Computed Tomography Pulmonary Angiography IVC: Inferior Vena Cava LGE: Late Gadolinium Enhancement PTFE: Polytetrafluoroethylene Declarations Ethics approval and consent to participate: Not applicable. Consent for publication: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Availability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Competing interests: The authors declare that they have no competing interests. Funding: No funding was received for the preparation or publication of this case report. Authors' contributions: OAE was the major contributor in writing the manuscript and overseeing the patient's clinical management. MG, MEA, MKS, and MAH analyzed and interpreted the multimodality imaging data, assisted in the urgent clinical intervention, and contributed to revising the manuscript. All authors read and approved the final manuscript. Acknowledgements: Not applicable. References 1. Rostamzadeh A, Khademvatani K, Rezaei Y, Sepehrvand N. Concurrent mobile and in situ types of right heart thrombi. J Tehran Heart Cent. 2014;9(2):90 − 2. 2. Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ; ICOPER Study Group. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003 Jun 18;41(12):2245-51. doi: 10.1016/s0735-1097(03)00479-0. 3. Ünlütürk S, Kauling RM, Cuypers JAAE, et al. Long-term outcome after surgical ventricular septal defect closure: Longitudinal follow-up into the fifth decade. Int J Cardiol Congenit Heart Dis. 2025 Oct 10;22:100624. doi: 10.1016/j.ijcchd.2025.100624 4. Boucher AA, Heneghan JA, Jang S, Spillane KA, Abarbanell AM, Steiner ME, Meyer AD. A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease. Front Surg. 2022 Jun 14;9:907782. doi: 10.3389/fsurg.2022.907782. 5. Hawe A, Rastelli GC, Brandenburg RO, McGoon DC. Embolic complications following repair of atrial septal defects. Circulation. 1969 May;39(5 Suppl 1):I185-91. doi: 10.1161/01.cir.39.5s1.i-185. 6. Yilmaz M, Gurlertop Y, Erdogan F. Right atrial thrombus following closure of an atrial septal defect. Heart. 2003 Jul;89(7):726. 7. González-Calle A, Adsuar-Gómez A, Moruno-Tirado A, Hosseinpour AR. Right atrial thrombosis and pulmonary embolism after atrial septal defect repair. Eur J Cardiothorac Surg. 2012 Jan;41(1):224-5. doi: 10.1016/j.ejcts.2011.05.035. 8. Pillai JB, Feindel CM, Butany J, Murphy P. A diagnostic challenge–an unusual right atrial mass, 12 years following atrial septal defect surgery. Interact Cardiovasc Thorac Surg. 2005 Aug;4(4):285-6. doi: 10.1510/icvts.2005.109512 9. Hofmeyr L, Pohlner P, Radford DJ. Long-term complications following surgical patch closure of multiple muscular ventricular septal defects. Congenit Heart Dis. 2013 Nov-Dec;8(6):541-9. doi: 10.1111/chd.12038. 10. Cuszynska-Kruk D, Fedchenko M, Giang KW, Dellborg M, Eriksson P, Hansson PO, Mandalenakis Z. Risk of venous thromboembolism in patients with congenital heart disease: a nationwide, register-based, case-control study. Eur Heart J Open. 2024 Oct 10;4(6):oeae089. doi: 10.1093/ehjopen/oeae089. 11. Lincoln C, Jamieson S, Joseph M, Shinebourne E, Anderson RH. Transatrial repair of ventricular septal defects with reference to their anatomic classification. J Thorac Cardiovasc Surg. 1977 Aug;74(2):183 − 90. 12. Turrentine MW, McCarthy RP, Vijay P, McConnell KW, Brown JW. PTFE monocusp valve reconstruction of the right ventricular outflow tract. Ann Thorac Surg. 2002 Mar;73(3):871-9; discussion 879 − 80. doi: 10.1016/s0003-4975(01)03441-5. 13. Kahyaoğlu M, Guner A, Gecmen C. Thrombus Formation in the Right Atrium after Surgical Closure of Atrial Septal Defect. J Cardiovasc Echogr. 2018 Oct-Dec;28(4):242–244. doi: 10.4103/jcecho.jcecho_34_18. 14. Ibrahim WH, Ata F, Choudry H, et al. Prevalence, Outcome, and Optimal Management of Free-Floating Right Heart Thrombi in the Context of Pulmonary Embolism, a Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost. 2022 Jan-Dec;28:10760296221140114. doi: 10.1177/10760296221140114. 15. Birnbaum B, Hahn E, Sheth SS, Steele J, Sachdeva R, Parthiban A, Statile C, Zaidi AN. Clinical Practice Algorithm for the Follow-Up of Unrepaired and Repaired Ventricular Septal Defects. American College of Cardiology. May 30, 2023. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 10 May, 2026 Reviews received at journal 06 May, 2026 Reviews received at journal 06 May, 2026 Reviews received at journal 05 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers agreed at journal 01 May, 2026 Reviewers agreed at journal 01 May, 2026 Reviewers agreed at journal 30 Apr, 2026 Reviews received at journal 29 Apr, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers invited by journal 29 Apr, 2026 Editor assigned by journal 20 Apr, 2026 Submission checks completed at journal 20 Apr, 2026 First submitted to journal 16 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9440854","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":635809492,"identity":"74b94171-5be9-4258-b503-67a3a236c47c","order_by":0,"name":"Osama Abouelfetouh Elshaer","email":"data:image/png;base64,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","orcid":"","institution":"Kafrelsheikh University","correspondingAuthor":true,"prefix":"","firstName":"Osama","middleName":"Abouelfetouh","lastName":"Elshaer","suffix":""},{"id":635809494,"identity":"0dcad363-dd06-4948-b736-66a5b86cb181","order_by":1,"name":"Mahmoud Gomaa","email":"","orcid":"","institution":"Kafrelsheikh University","correspondingAuthor":false,"prefix":"","firstName":"Mahmoud","middleName":"","lastName":"Gomaa","suffix":""},{"id":635809496,"identity":"defe66a9-e3e5-4dd3-b5cd-90d95b1c8c6f","order_by":2,"name":"Mohamed Elsayed Abdelfattah","email":"","orcid":"","institution":"Kafrelsheikh University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Elsayed","lastName":"Abdelfattah","suffix":""},{"id":635809498,"identity":"c402ad1b-62e1-490d-b8b2-4d02552cbdea","order_by":3,"name":"Mohamed Kamal Salama","email":"","orcid":"","institution":"Kafrelsheikh University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Kamal","lastName":"Salama","suffix":""},{"id":635809500,"identity":"e67a3669-2831-48fa-b76b-528c74b07c90","order_by":4,"name":"Mohammad Ali Hammad","email":"","orcid":"","institution":"Kafrelsheikh University","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Ali","lastName":"Hammad","suffix":""}],"badges":[],"createdAt":"2026-04-16 17:08:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9440854/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9440854/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108957590,"identity":"ac5b2764-c0c9-4db2-a034-935ae2dd9c07","added_by":"auto","created_at":"2026-05-11 08:20:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":277624,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTransthoracic and Transesophageal Echocardiography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend: Panel (A):\u003c/strong\u003e Apical 4-chamber view of transthoracic echo showing dilated right atrium and right ventricle as well as thickened Tricuspid Valve, with a well-defined, lobular, freely mobile RA mass measuring ~22 x 14 mm; \u003cstrong\u003ePanels (B and C):\u003c/strong\u003e mid-esophageal right-sided focused views at 0° and 40° of transesophageal echo further enhancing the right atrial mass.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9440854/v1/33bc47d21964a3f452bccb66.png"},{"id":108957592,"identity":"8931303a-aa11-459a-83d1-07c1864cc7f9","added_by":"auto","created_at":"2026-05-11 08:20:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":411040,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eContrast-enhanced CT pulmonary angiography (CTPA)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e \u003cstrong\u003ePanel (A):\u003c/strong\u003e Axial CTPA image showing a right atrial intracavitary mass; \u003cstrong\u003ePanels (B) \u0026amp; (C):\u003c/strong\u003e Axial CTPA images showing filling defects in the right main pulmonary artery and within a right subsegmental pulmonary arterial branch, consistent with pulmonary emboli.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9440854/v1/64b6e3fe290697f05822a4b3.png"},{"id":108957591,"identity":"baf69957-1cc1-4668-b23e-94dc06e56318","added_by":"auto","created_at":"2026-05-11 08:20:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":269892,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCardiac Magnetic Resonance Imaging (CMR)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend: \u003c/strong\u003eCMR images for tissue characterizing of the RA mass suggesting a thrombus; \u003cstrong\u003ePanel (A):\u003c/strong\u003e Iso- to Hyper-intense signal in T2; \u003cstrong\u003ePanel (B):\u003c/strong\u003e Iso-intense signal in T1; \u003cstrong\u003ePanel (C):\u003c/strong\u003e Etched appearance at late Gadolinium enhancement (LGE); and \u003cstrong\u003ePanel (D):\u003c/strong\u003e no significant contrast uptake at perfusion.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9440854/v1/1acfe80d1b48a9c14f73e4be.png"},{"id":108978166,"identity":"4a87c20f-62c1-4aa1-81ec-33148f3934d3","added_by":"auto","created_at":"2026-05-11 11:34:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":552423,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOutcomes of Surgical Mass Excision and Pulmonary Embolectomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A): \u003c/strong\u003eIntraoperative photograph during the open-heart surgery showing the operative field at the time of right atrial mass excision;\u003cstrong\u003ePanels (B) \u0026amp; (C): \u003c/strong\u003eGross specimens following surgery, including the excised right atrial mass and extracted pulmonary arterial embolic material \u003cstrong\u003ePanel (D) \u003c/strong\u003ePost-procedural TEE, mid-esophageal 4-chamber view (0°), showing the right atrium free of any residual mass.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9440854/v1/ae07becb764bb4c77391e7bd.png"},{"id":109067519,"identity":"49f7a013-0ae8-4fff-bdd5-2c760b5f0b86","added_by":"auto","created_at":"2026-05-12 09:55:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2036193,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9440854/v1/7ae71b9f-d459-4800-a429-d9dd08bdc849.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Right Atrial Thrombus and Pulmonary Embolism One Year After Ventricular Septal Defect Patch Repair: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eRight heart thrombi (RHT) are a rare but life-threatening clinical entity, classically categorized as either \u0026ldquo;thrombi-in-transit\u0026rdquo; originating from the deep venous system or mural thrombi forming in situ in the setting of structural or congenital heart disease or intracardiac foreign material [1]. Mortality is high, particularly when complicated by pulmonary embolism (PE) [2].\u003c/p\u003e \u003cp\u003eCardiac surgery can create a thrombogenic substrate through atriotomy suture lines, prosthetic or patch material, and altered right-sided flow, allowing in-situ RHT formation that may subsequently present as PE. However, data on long-term thromboembolic (TE) outcomes specifically after surgical Ventricular Septal Defect (VSD) closure remain limited [3]. Additionally, post\u0026ndash;VSD repair surveillance and TE prophylaxis for RHT remain controversial and are typically individualized on a case-by-case basis [4].\u003c/p\u003e \u003cp\u003eIn this report, we describe a highly unusual case of a massive right atrial (RA) thrombus with PE occurring in a young patient one year after VSD repair, in the absence of any known hypercoagulable state.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 17-year-old male with a history of congenital perimembranous VSD diagnosed at birth (measuring 6 mm) presented with acute-onset shortness of breath, markedly decreased exercise tolerance, and palpitations that began two days prior to evaluation. He had been regularly followed up until undergoing surgical VSD GORE-TEX\u0026reg; patch (expanded PTFE) closure with concomitant tricuspid valve repair using ring annuloplasty approximately 12 months before the current presentation. During this follow-up, his postoperative course was uncomplicated, and baseline preoperative and early postoperative transthoracic echocardiography (TTE) demonstrated successful repair without evidence of intracardiac masses or thrombi.\u003c/p\u003e \u003cp\u003eHe presented initially to the cardiology outpatient clinic in a state of hemodynamic compromise, with a blood pressure of 90/60 mmHg, heart rate of 135 beats/min, respiratory rate of 35 breaths/min, and oxygen saturation of 80% on room air. On physical examination, he appeared distressed and tachypneic. Neck exam showed mild jugular venous distension and there was no lower limb edema.\u003c/p\u003e \u003cp\u003eElectrocardiography (ECG) showed sinus tachycardia. Urgent transthoracic echocardiography (TTE) identified a well-defined, lobular, freely mobile RA mass measuring 22 x 14 mm and attached to the crista terminalis \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Given the severity of hypoxemia and concern for TE pathology, the patient was admitted immediately to the cardiac care unit (CCU) and therapeutic anticoagulation was initiated (Enoxaparin 60 mg SC q12h). CT pulmonary angiography was done, and -in addition to the RA mass- it revealed a large central filling defect in the right main pulmonary artery, with multiple additional filling defects in the right-sided branches \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Given evidence of massive PE with hemodynamic compromise, therapeutic anticoagulation with enoxaparin was continued, and the patient was kept in the CCU and managed with supportive measures.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo further characterize the RA mass and distinguish thrombus from alternative etiologies, cardiac magnetic resonance (CMR) imaging was performed, which showed the mass displaying iso-intense signal in T1 and iso- to hyper-intense signal in T2 and no significant contrast uptake at perfusion, supporting the diagnosis of an intracardiac thrombus over a tumor or vegetation \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e A comprehensive thrombophilia evaluation was negative. Additionally, there was no prior personal history of venous TE, no family history of thrombophilia, and no indwelling central venous catheter.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDespite anticoagulation, the patient experienced clinical deterioration over the subsequent 2 days, with worsening dyspnea and increasing distress. Given the progressive clinical trajectory and imaging findings, decision was reached by a multidisciplinary team of cardiologists and cardiac surgeons to proceed with urgent cardiac surgery. Notably, the subcostal IVC long-axis TTE view incidentally revealed a 19 x 15 mm hepatic lesion consistent with a hemangioma \u003cb\u003e(Supplementary Figure)\u003c/b\u003e. Although there were no clinical or laboratory features of active bleeding, we deferred systemic thrombolysis for PE management and surgical decision was made given the patient\u0026rsquo;s further clinical deterioration, the concomitant RA mass, and the anticipated need for urgent surgical intervention.\u003c/p\u003e \u003cp\u003eFour days from admission, the patient underwent successful excision of the RA mass and pulmonary embolectomy. Surgery achieved complete removal of an organized RA thrombus and multiple PE \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Histopathology confirmed the excised mass nature to be a thrombus. Postoperatively, the patient was successfully weaned from mechanical ventilation, extubated, and achieved hemodynamic stabilization, and he remains hemodynamically stable at present.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIt is well recognized that repair of adult congenital heart defects can be complicated by TE events [5]. Late TE complications after either device closure or surgical patch septal defects closure have been previously reported in the literature [6\u0026ndash;8]. However, all published reports were following ASD closure. Long-term complications following VSD repair were explored by Hofmeyr et al., who suggested that reduced RV size and diastolic dysfunction may be associated with right heart failure and arrhythmias without mentioning a significant risk for RHT [9]. However, in a nationwide case-control study, individuals with VSD had a significantly higher risk of venous thromboembolism (VTE) compared with matched controls, suggesting that VSD is associated with increased TE risk even when repair status is not specified [10]. Despite this, RA thrombosis following VSD repair in the absence of any known hypercoagulable state or indwelling catheters appears extremely rare and, to our knowledge, has not been previously reported; we believe this is the first report of this complication.\u003c/p\u003e \u003cp\u003eLooking into literature, we found some reports that could explain the course of our challenging case. Since most VSD repairs are commonly performed via a transatrial approach to access the VSD through the TV, a post-atriotomy scar / irregular endocardial surface can promote local thrombosis leading to a late RA thrombus arising from the right-atrial incision site [11]. As we previously mentioned, it\u0026rsquo;s worth noting that our patient\u0026rsquo;s VSD closure surgery one year before presentation was done concomitantly with tricuspid valve repair. Additionally, post-repair atrial thrombi have been described in relation to surgical closure sites, with foreign material and suture lines considered potential thrombogenic triggers [12, 13]. This is supported by histopathologic findings showing focal regions of endothelialization along patch material in explanted specimens [12].\u003c/p\u003e \u003cp\u003eIn cases of large, mobile RA thrombi with PE and clinical deterioration, a timely aggressive approach including surgical thrombectomy and embolectomy is often pursued, as observational data suggest that thrombolysis and surgical thrombectomy are associated with better survival in these patients [14]. However, TE prophylaxis strategies following VSD surgical repair remain unclear. The American College of Cardiology (ACC) clinical practice algorithm notes that surgically repaired VSDs can be followed every 2\u0026ndash;5 years, and an echocardiogram is not routinely needed unless there is residual VSD or a clinical change [15]. A narrative review of postoperative anticoagulation in congenital heart disease notes that ASD and VSD repairs have historically not required routine anticoagulation, and when used after septal defect repair, it is typically reserved for higher-risk situations rather than isolated defects [4]. Ongoing research is warranted to better define optimal postoperative follow-up imaging and TE prophylaxis strategies for this population.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur case represents an extremely rare presentation of late right atrial thrombus with pulmonary embolism one year after surgical VSD patch closure and tricuspid valve repair, occurring in the absence of an identified hypercoagulable state and requiring timely surgical intervention. Further studies are warranted to better define postoperative surveillance strategies and thromboprophylaxis for comparable postoperative scenarios.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eVSD:\u0026nbsp;\u003c/strong\u003eVentricular Septal Defect\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eASD:\u003c/strong\u003e Atrial Septal Defect\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePE:\u0026nbsp;\u003c/strong\u003ePulmonary Embolism\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRA:\u003c/strong\u003e Right Atrium\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRHT:\u0026nbsp;\u003c/strong\u003eRight Heart Thrombi\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTE:\u003c/strong\u003e Thromboembolism\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVTE:\u003c/strong\u003e Venous Thromboembolism\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTV:\u003c/strong\u003e Tricuspid Valve\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTTE:\u0026nbsp;\u003c/strong\u003eTransthoracic Echocardiography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTEE:\u0026nbsp;\u003c/strong\u003eTransesophageal Echocardiography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCCU:\u003c/strong\u003e Cardiac Care Unit\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCMR:\u003c/strong\u003e Cardiac Magnetic Resonance\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eECG:\u003c/strong\u003e Electrocardiography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCTPA:\u003c/strong\u003e Computed Tomography Pulmonary Angiography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIVC:\u003c/strong\u003e Inferior Vena Cava\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLGE:\u003c/strong\u003e Late Gadolinium Enhancement\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePTFE:\u003c/strong\u003e Polytetrafluoroethylene\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNo funding was received for the preparation or publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eOAE was the major contributor in writing the manuscript and overseeing the patient\u0026apos;s clinical management. MG, MEA, MKS, and MAH analyzed and interpreted the multimodality imaging data, assisted in the urgent clinical intervention, and contributed to revising the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e1. Rostamzadeh A, Khademvatani K, Rezaei Y, Sepehrvand N. Concurrent mobile and in situ types of right heart thrombi. J Tehran Heart Cent. 2014;9(2):90\u0026thinsp;\u0026minus;\u0026thinsp;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e2. Torbicki A, Gali\u0026eacute; N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ; ICOPER Study Group. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003 Jun 18;41(12):2245-51. doi: 10.1016/s0735-1097(03)00479-0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e3. \u0026Uuml;nl\u0026uuml;t\u0026uuml;rk S, Kauling RM, Cuypers JAAE, et al. Long-term outcome after surgical ventricular septal defect closure: Longitudinal follow-up into the fifth decade. Int J Cardiol Congenit Heart Dis. 2025 Oct 10;22:100624. doi: 10.1016/j.ijcchd.2025.100624\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e4. Boucher AA, Heneghan JA, Jang S, Spillane KA, Abarbanell AM, Steiner ME, Meyer AD. A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease. Front Surg. 2022 Jun 14;9:907782. doi: 10.3389/fsurg.2022.907782.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e5. Hawe A, Rastelli GC, Brandenburg RO, McGoon DC. Embolic complications following repair of atrial septal defects. Circulation. 1969 May;39(5 Suppl 1):I185-91. doi: 10.1161/01.cir.39.5s1.i-185.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e6. Yilmaz M, Gurlertop Y, Erdogan F. Right atrial thrombus following closure of an atrial septal defect. Heart. 2003 Jul;89(7):726.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e7. Gonz\u0026aacute;lez-Calle A, Adsuar-G\u0026oacute;mez A, Moruno-Tirado A, Hosseinpour AR. Right atrial thrombosis and pulmonary embolism after atrial septal defect repair. Eur J Cardiothorac Surg. 2012 Jan;41(1):224-5. doi: 10.1016/j.ejcts.2011.05.035.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e8. Pillai JB, Feindel CM, Butany J, Murphy P. A diagnostic challenge\u0026ndash;an unusual right atrial mass, 12 years following atrial septal defect surgery. Interact Cardiovasc Thorac Surg. 2005 Aug;4(4):285-6. doi: 10.1510/icvts.2005.109512\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e9. Hofmeyr L, Pohlner P, Radford DJ. Long-term complications following surgical patch closure of multiple muscular ventricular septal defects. Congenit Heart Dis. 2013 Nov-Dec;8(6):541-9. doi: 10.1111/chd.12038.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e10. Cuszynska-Kruk D, Fedchenko M, Giang KW, Dellborg M, Eriksson P, Hansson PO, Mandalenakis Z. Risk of venous thromboembolism in patients with congenital heart disease: a nationwide, register-based, case-control study. Eur Heart J Open. 2024 Oct 10;4(6):oeae089. doi: 10.1093/ehjopen/oeae089.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e11. Lincoln C, Jamieson S, Joseph M, Shinebourne E, Anderson RH. Transatrial repair of ventricular septal defects with reference to their anatomic classification. J Thorac Cardiovasc Surg. 1977 Aug;74(2):183\u0026thinsp;\u0026minus;\u0026thinsp;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e12. Turrentine MW, McCarthy RP, Vijay P, McConnell KW, Brown JW. PTFE monocusp valve reconstruction of the right ventricular outflow tract. Ann Thorac Surg. 2002 Mar;73(3):871-9; discussion 879\u0026thinsp;\u0026minus;\u0026thinsp;80. doi: 10.1016/s0003-4975(01)03441-5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e13. Kahyaoğlu M, Guner A, Gecmen C. Thrombus Formation in the Right Atrium after Surgical Closure of Atrial Septal Defect. J Cardiovasc Echogr. 2018 Oct-Dec;28(4):242\u0026ndash;244. doi: 10.4103/jcecho.jcecho_34_18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e14. Ibrahim WH, Ata F, Choudry H, et al. Prevalence, Outcome, and Optimal Management of Free-Floating Right Heart Thrombi in the Context of Pulmonary Embolism, a Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost. 2022 Jan-Dec;28:10760296221140114. doi: 10.1177/10760296221140114.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e15. Birnbaum B, Hahn E, Sheth SS, Steele J, Sachdeva R, Parthiban A, Statile C, Zaidi AN. Clinical Practice Algorithm for the Follow-Up of Unrepaired and Repaired Ventricular Septal Defects. American College of Cardiology. May 30, 2023.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cardiac Surgery, Case Report, Intracardiac Mass, Pulmonary Embolism, Ventricular Septal Defect","lastPublishedDoi":"10.21203/rs.3.rs-9440854/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9440854/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRight heart thrombi are rare but life-threatening, with particularly high mortality when accompanied by pulmonary embolism (PE). Cardiac surgery may predispose to in-situ thrombus formation via suture lines or patch material, yet thromboembolic risk and preventive strategies following Ventricular Septal Defect (VSD) repair remain unclear. Here, we report a case of a young patient with a massive right atrial (RA) thrombus with PE one year after VSD repair in the absence of any known hypercoagulable state.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 17-year-old male with a history of surgical VSD repair one year earlier, who was not taking any antithrombotic therapy prior to presentation, presented with acute dyspnea, tachycardia, and severe hypoxia. Transthoracic echocardiography revealed a large, freely mobile RA mass. Subsequent CT pulmonary angiography and cardiac magnetic resonance confirmed a massive right pulmonary artery embolus and characterized the RA mass as an intracardiac thrombus. Because of clinical deterioration despite therapeutic anticoagulation, he underwent a successful urgent cardiac surgery with RA mass excision and pulmonary embolectomy. Postoperative histopathology confirmed the mass to be a thrombus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur case highlights a rare late RA thrombus with PE one year after surgical VSD repair, requiring urgent surgery. Further research is needed to clarify post–VSD closure surveillance and thromboprophylaxis strategies.\u003c/p\u003e","manuscriptTitle":"Right Atrial Thrombus and Pulmonary Embolism One Year After Ventricular Septal Defect Patch Repair: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 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