A Seedless Grape in the Heart.

A 65-year-old woman was admitted with shortness of breath and chest pain. A computed tomographic angio-gram of the chest performed for suspected pulmonary embo-lism showed a filling defect in the left atrium, concerning for a tumor or thrombus (Figure, A). Transesophageal echo-cardiography revealed a large mobile mass in the left atrium attached to the interatrial septum with a very short pedicle (Figure, B and Movie I in the online-only Data Supplement). The patient had a history of surgical patent foramen ovale closure with a Prolene suture, mitral valve repair, and saphenous vein bypass graft to the right coronary artery a year and a half previously. Her antithrombotic therapy after surgery was aspirin. She had no history of atrial fibrillation, arterial or venous thromboembolic disease, recent infections, or intravascular or cardiac devices. Considering the high risk of embolism, surgical removal of the mass was planned. A coronary angiogram before the operation showed an occluded vein graft and progression of left anterior descending artery disease. On surgical exploration, the mass was loosely attached to the interatrial septum and left atrial trabeculae and did not involve the mitral valve or the mitral repair ring (Figure, C). The mass was reddish tan, roughly oval, and 2.5×2×1.5 cm and had a rubbery consistency (Figure, D). Histopathological analysis was consistent with an organized blood clot (Figure, E and F). A radial artery bypass graft to the posterior descending artery and an in situ left internal mammary artery to left anterior descending artery graft were also performed. The patient had an uneventful recovery and was discharged to home on aspirin and clopidogrel. A small incidence of thrombus formation on patent fora-men ovale closure devices has been reported, with a higher risk in patients with postprocedural atrial fibrillation and persistent atrial septal aneurysm. There are no known reports of thrombus formation at or near the site of surgical closure of a patent foramen ovale in short-or long-term follow-up. The underlying pathophysiology of thrombus formation near the surgical closure site of patent foramen ovale in the present case remains unknown.