Diagnosis of right atrial mass by perioperative transesophageal echocardiography

A 67-year-old lady presented with shortness of breath, and was found to have severe triple vessel disease by coronary angiography. Transthoracic echocardiography (TTE) was reported as normal. However a large cystic mass was unexpectedly found in the right atrium by intra-operative transesophageal echocardiography (TOE). This mass was attached to the anterior wall, just by the inter-atrial septum. Flow was demonstrated within the mass by colour flow doppler. The right atrium was opened and the mass excised during cardio-pulmonary bypass. A right coronary artery aneurysm was diagnosed, which was confirmed on histopathological examination. The importance of intra-operative TEE in demonstrating new findings and changing management is highlighted. Coronary artery aneurysm may predispose to embolism or thrombosis if untreated, and may not be seen on angiography or TTE, as in this case.