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Archives of cardiovascular diseases
Volume 102, n° 8-9
pages 663-664 (août 2009)
Doi : 10.1016/j.acvd.2009.04.014
Received : 10 April 2009 ;  accepted : 21 April 2009
Right atrial mass complicating aortic endocarditis
Masse atriale droite compliquant une endocardite aortique

Pierre-Laurent Massoure , Lina Zapata, Jean-Luc Caumes
Hôpital des Armées Bouffard, SP 85024, 00812 Djibouti, Djibouti 

Corresponding author. Fax: +253 35 24 35.

Keywords : Infective endocarditis, Aorto-cavitary fistula, Pediculated thrombus

Mots clés : Endocardite infectieuse, Fistule aorto-cavitaire, Thrombus pédiculé

A 37-year-old Djiboutian man presented to hospital with rheumatic aortic stenosis (aortic valve area 0.7cm2/m2). The patient became symptomatic with dyspnoea and fever. The aortic valve area was unchanged with mild aortic regurgitation. Transthoracic echocardiography revealed a pediculated round mass (25×20mm) floating inside the right atrium (Figure 1, panel A). Three successive blood cultures were positive for Streptococcus viridans , with a dental entry site. Infective endocarditis was confirmed on transoesophageal echocardiography. A posterior aortic ring abscess (17×12mm) ruptured into the right atrium creating an aortic-right atrial fistula and causing a highly mobile vegetative mass in the right atrium (Figure 1, panel B) with no valvular vegetation. The patient had multiple organ failure and acute respiratory distress syndrome, which was probably due to multiple pulmonary emboli. There were no other clinical signs of septic embolus. There are no cardiovascular surgical centres in the Horn of Africa, and the patient died a few days after the diagnosis despite intensive care.

Figure 1

Figure 1. 

Panel A. Transthoracic echocardiography demonstrating right atrial mass (left) confirmed on transesophageal echocardiography (right).

Panel B. Transesophageal echocardiography (Colour Doppler mode) demonstrating right atrial mass (small arrow) and aortic right atrial fistula (large arrow).

Ao: aortic ring; LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle.


Aortic ring abscess is a frequent complication of infective endocarditis. Aorto-cavitary fistula is less frequent, representing less than 2% of cases of native aortic valve endocarditis. The report of a patient with a right atrial mass complicating an aortic ring abscess with fistula is exceptional. The diagnosis of a cardiac tumour could be excluded because the mass was absent 4 months earlier (evidenced on a previous echocardiographic evaluation). This echo-dense mass, mimicking a thrombus, was certainly an infected thrombotic vegetation, and the lack of surgical facilities led to the patient’s death.

Conflict of interests

None declared.

Appendix A. Supplementary data

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