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Case Reports
. 2025 Dec 2;17(12):e98329.
doi: 10.7759/cureus.98329. eCollection 2025 Dec.

A Pseudo-Right Atrial Mass in Massive Pulmonary Embolism: A Case Report Highlighting Multimodality Imaging and Multidisciplinary Team Review

Mehak Gupta  1 , Aaditya Kodamanchile  1 , Louise Tamin  1 , Pavithralakshmi Venkatraghavan  2 , Andrew Cole  1
Affiliations
Case Reports

A Pseudo-Right Atrial Mass in Massive Pulmonary Embolism: A Case Report Highlighting Multimodality Imaging and Multidisciplinary Team Review

Mehak Gupta et al. Cureus. .

Abstract

Transthoracic echocardiography (TTE) is often the first-line imaging modality in cardiac assessment due to its accessibility and rapid acquisition. However, compared with cardiac magnetic resonance (CMR), it offers limited tissue characterisation and may misinterpret anatomical variants as pathology. Consequently, multimodality imaging and multidisciplinary team (MDT) review are frequently required for accurate diagnosis. A 44-year-old man presented with acute dyspnoea following long-haul travel. Computerised tomography pulmonary angiography revealed massive bilateral pulmonary emboli without right ventricular strain, and he was treated with rivaroxaban 20 mg once a day. Three months later, follow-up TTE demonstrated a right atrial mass, reported as a possible thrombus, prompting anticoagulation change to warfarin. At six months, CMR showed no intracardiac mass. However, repeat TTE at one year again suggested a right atrial mass. A review during the cardiac imaging MDT concluded that the apparent "mass" represented epicardial fat entering the imaging plane. Rivaroxaban 20 mg once a day was reinstated for indefinite anticoagulation. This diagnostic pitfall led to an unnecessary switch to warfarin, highlighting how misinterpretation of anatomical variants can significantly alter clinical management. This case underscores the critical role of multimodality imaging and MDT review in the evaluation of intracardiac masses to prevent misdiagnosis and unnecessary treatment.

Keywords: direct oral anticoagulant therapy; mri cardiac; multidisciplinary teams; right atrial cardiac mass; transthoracic echocardiogram.

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Conflict of interest statement

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Axial contrast-enhanced CT pulmonary angiography demonstrating extensive bilateral pulmonary emboli.
(A–D) Red arrows indicate intraluminal filling defects consistent with acute pulmonary emboli involving the segmental and subsegmental branches of the pulmonary arteries. Images illustrate emboli in both the right and left pulmonary arterial trees at different axial levels, showing extensive clot burden and distribution.
Figure 2
Figure 2. Transthoracic echocardiography demonstrating a right atrial mass.
Apical four-chamber view showing a well-defined echogenic mass within the right atrium (red arrow).
Figure 3
Figure 3. Cardiac magnetic resonance (CMR) imaging confirming absence of a true intracardiac mass.
(A) Steady-state, free precession, four-chamber, cine CMR image showing extracardiac fat invaginating into the right atrium (yellow arrow). (B) End-systolic frame of the same image series with extracardiac fat (yellow arrow).
See this image and copyright information in PMC

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