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The Best Laid Plans with a Suspected Right Atrial Mass and Pulmonary Hypertension
Abstract Number: RF1BA-517
Abstract Type: Case Report Case Series
The mortality of pregnant patients with pulmonary arterial hypertension (PAH) remains high, with some reports of 35-50% (1). Newer therapies and clinical strategies may be improving outcomes, however, this remains a dangerous diagnosis to carry especially in the setting of additional complex medical issues which inhibit the diagnostic performance of right heart catheterization (RHC) such as a right atrial mass (2). In the adult population, atrial masses can be due to a primary cardiac tumor, an intracardiac thrombus or endocarditis vegetation, all of which carry physiologic consequences including intracardiac flow obstruction, pulmonary embolism, and arrhythmia (3,4). Even though parturients with pulmonary hypertension are rare, the combination of PAH and right atrial mass makes the creation of an effective and safe labor plan especially challenging. Unfortunately, in spite of the best laid plans, unexpected circumstances present themselves. We describe such a case where a carefully constructed plan involving advanced, multidisciplinary planning was aborted due to a precipitous delivery.
AN was a 33 yo G4P3 @ 37+4 with PMH of obesity (BMI 39), HTN, suspected RA mass and PAH, restrictive lung disease, scoliosis, gDM, anemia, and anxiety who presented to L&D two days prior to starting her IOL for medical optimization. Over the previous month multidisciplinary meetings were held to discuss the labor plan and further workup including a cardiac CT (cCT) and RHC to evaluate both her suspected right heart mass and PAH. Even though the cCT confirmed the absence of a right heart mass, the patient refused a RHC. Preparations were made for delivery with the assumption of the presence of PAH including invasive monitoring and inhaled NO. Despite extensive preparation and resource utilization, the patient precipitously delivered without further intervention. She was transferred to the MICU where NO was discontinued within hours without further complications.
RA masses are rare in any population, but this diagnosis in the presence of pulmonary hypertension borders on the frequency of a unicorn sighting. This case highlights that while multidisciplinary planning is critical, providers should remain vigilant to avoid over treating, especially in a stable patient.
1. Pitkin RM, Perloff JK, Koos BJ, Beall MH. Pregnancy and Congenital Heart Disease. Ann Intern Med. 1990 Mar; 112:445–454.
2. Bedard E, Dimopoulos K, Gatzoulis M. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension? Eur Heart Jrnl. 2009 Feb; 30-3. 256-265.
3. Swartz, M. F., Lutz, C. J., Chandan, V. S., Landas, S. and Fink, G. W. , Atrial Myxomas: Pathologic Types, Tumor Location, and Presenting Symptoms. Jrnl of Card Surg. 2006. 21: 435-440.
4. Panidis IP, Kotler MN, Mintz GS, et al: Clinical and echocardiographic features of right atrial masses. Am Heart J. 1984;107: 745–758.