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Table of Contents
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 142-144

An interesting case of normal variant misinterpreted as left atrial mass

1 Department of Cardiology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
2 Department of Paediatric Cardiology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India

Date of Submission13-May-2020
Date of Decision06-Jul-2020
Date of Acceptance03-Jun-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. Rajesh Natuva
Krishna Institute of Medical Sciences, Secunderabad, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JICC.JICC_32_20

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Coumadin ridge is a normal anatomical variant that is found in the left atrium (LA). We present a case of a LA mass in a 69-year-old patient, diagnosed during preoperative evaluation for total knee replacement and hence referred for surgical resection of the atrial mass. Detailed and meticulous transthoracic and transesophageal echocardiographic examination revealed it as a prominent Coumadin ridge between the left superior pulmonary vein and LA appendage with a bulbous tip, confused initially as an LA mass. The echocardiographic appearance of Coumadin ridge is described as “Q-tip sign.” It can be differentiated with other structures, such as thrombus/atrial mass, because of its property of being at a specific location, lack of mobility, and unique linear structure with a rounded bulbous tip. This case highlights the importance of proper knowledge and the need for careful evaluation of normal structural variants to avoid unnecessary workup and treatment.

Keywords: Coumadin ridge, left atrial myxoma, left atrial thrombus, Q-tip sign

How to cite this article:
Natuva R, Verma S, C. Padmanabhan T N. An interesting case of normal variant misinterpreted as left atrial mass. J Indian coll cardiol 2020;10:142-4

How to cite this URL:
Natuva R, Verma S, C. Padmanabhan T N. An interesting case of normal variant misinterpreted as left atrial mass. J Indian coll cardiol [serial online] 2020 [cited 2022 Aug 14];10:142-4. Available from: https://www.joicc.org/text.asp?2020/10/3/142/304376

  Introduction Top

With improving imaging modalities, several normal anatomic variants have come to our attention. Coumadin ridge is one of the normal structural variants, which refers to a part of the left atrium (LA) that lies between the LA appendage and the left superior pulmonary vein. Since this is a not common finding, and due to its shape and location, it has the potential of being misdiagnosed as an LA mass or thrombus.

  Case Report Top

A 69-year-old female presented with shortness of breath on exertion NYHA Functional Class II symptoms for 6 months not associated with chest heaviness/palpitations/syncope/orthopnea/ Paroxysmal nocturnal dyspnoea (PND). During routine evaluation elsewhere for fitness for orthopaedic procedure, screening echocardiography was done and suspected to have left atrial mass or thrombus. Hence referred for further detailed cardiac evaluation. Physical examination vitals are stable. Cardiovascular and other system examination was unremarkable. Chest X-ray [Figure 1] and electrocardiography were normal [Figure 2]. Transthoracic echocardiography (TTE) revealed good left ventricular function, normal LA size, and LA appendage with a prominent mass in the LA with a thin tail and bulbous tip, initially thought to be a tumor, but meticulous examination showed that it is the structure present in between LA appendage and left superior pulmonary vein more consistent with Coumadin ridge [Figure 3]. The above findings were confirmed with the transesophageal echocardiogram (TEE) also [Figure 4]. One of the main differentiating features of a ridge from thrombus is its location and typical bulbous tip and a thin tail-like appearance commonly referred to as “Q-tip sign” of echocardiogram.
Figure 1: Chest x-ray

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Figure 2: ECG showing Normal Sinus Rhythm

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Figure 3: 2D Echo showing prominent mass between LAA and LSPV

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Figure 4: TEE showing prominent Coumadin ridge in Various views

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  Discussion Top

The Coumadin ridge also known as the Warfarin ridge or the LA pseudotumor is a prominent, muscular ridge of the tissue that lies in the LA in between the left superior pulmonary vein and the LA appendage.[1] Q tip is ear bud brand in USA hence referred as “ear bud sign” also. One of its components is the ligament of Marshall, a remnant of the left superior vena cava, extending along the recess. It may often appear to be attached to the roof of the LA appendage, with a rounded end extending into the LA. Due to this rounded end, the Coumadin ridge is often referred to as a “Q-tip sign” on echocardiography.[1] It is important to keep in mind that it may not always appear rounded. When viewing it in the parasternal long-axis view, it may appear as a linear band within the LA.[1] Furthermore, when several cross-sections of heart specimens were looked at along their narrowest point, 75% of the samples were shown to be round, 5% flat, and 10% pointed.[2] Due to its rounded or bulbous tip, it appears to be like thrombus/myxoma [Table 1]. It can be diagnosed easily with TTE,[1],[3],[4] if in doubt contrast echo or TEE[5],[6] or three-dimensional echo[1] or rarely cardiac magnetic resonance imaging (MRI)[4],[7],[8] helps in confirming the diagnosis [Table 1].
Table 1: Differentiating features of Coumadin ridge, thrombus, and myxoma

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It is important to know about this variant because:

  1. Erroneous diagnosis may lead to unnecessary surgical or medical intervention[2],[3]
  2. The ridge has muscular connections with the left superior pulmonary vein, which can act as triggering substrate of focal atrial fibrillation, becoming a potential site for ablation[9]
  3. Its presence indicates the normal opening of the left upper pulmonary vein into the LA, thus ruling out Total anomalous pulmonary venous connection (TAPVC) prenatally in the fetal echo.[10]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

  Conclusion Top

It is important to recognize normal structural variants of the heart to avoid misdiagnosis and unnecessary investigation and treatment. Coumadin ridge is one such normal variant which easily gets confused with LA mass or LA thrombus. Its immobile nature with unique linear structure and bulbous tip with a characteristic location between the left superior pulmonary vein and LA appendage distinguishes it from mass or thrombus. In case of difficulty in interpretation through TTE, it is advisable to do TEE or rarely MRI to confirm the diagnosis.

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Conflicts of interest

There are no conflicts of interest.

  References Top

McKay T, Thomas L. Coumadin ridge in the left atrium demonstrated on three-dimensional transthoracic echocardiography. Eur J Echocardiogr 2008;9:298-300.  Back to cited text no. 1
Ho SY, McCarthy KP, Faletra FF. Anatomy of the left atrium for interventional echocardiography. Eur J Echocardiogr 2011;12:i11-5.  Back to cited text no. 2
George A, Parameswaran A, Nekkanti R, Lurito K, Movahed A. Normal anatomic variants on transthoracic echocardiogram. Echocardiography 2009;26:1109-17.  Back to cited text no. 3
Agostini F, Click RL. More than just the “Q-tip sign”. J Am Soc Echocardiogr 2001;14:832-3.  Back to cited text no. 4
Perrino AC, Reeves ST. A practical approach to transesophageal echocardiography. 3rd ed.. Philadelphia: Lippincott Williams and Wilkins; 2013;458.  Back to cited text no. 5
Oxom DC. Intraoperative Echocardiography. 1st ed.. Philadelphia: Saunders; 2012. p. 241-69.  Back to cited text no. 6
Gupta S, Plein S, Greenwood JP. The Coumadin ridge: An important example of a left atrial pseudotumour demonstrated by cardiovascular magnetic resonance imaging. J Radiol Case Rep 2009;3:1-5.  Back to cited text no. 7
Chaothawee L. The Coumadin ridge: Why do we need to know about it? Bangkok Med J 2015;9:83-5.  Back to cited text no. 8
Kistler PM, Earley MJ, Harris S, Abrams D, Ellis S, Sporton SC, et al. Validation of three-dimensional cardiac image integration: Use of integrated CT image into electroanatomic mapping system to perform catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2006;17:341-8.  Back to cited text no. 9
Ganesan S, Brook MM, Silverman NH, Moon-Grady AJ. Prenatal findings in total anomalous pulmonary venous return: A diagnostic road map starts with obstetric screening views. J Ultrasound Med 2014;33:1193-207.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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