[HSF] Antiphospholipid Syndrome

[Hgrmd at aol.com]

Dear Members:
  I need some advice on how to handle this case.  This 47 yo man  was 
admitted with gangrenous toes.  He had palpitations secondary to atrial  flutter.  
His past history was significant for DVT for which he had been on  Coumadin.  No 
h/o PE.  Workup in the past had apparently supported the  diagnosis of 
antiphospholipid syndrome.  
  I'm not quite sure why, but he ended up with a contrast chest  CT.  It 
revealed lamination of apparent clot that concentrically occupied  2/3's of the 
lumen.  They did a TEE which was consistent with the CT.   There were no 
significant valvular abnormalities.  The RV functioned  well.   There was only trace 
TR.  
  My working diagnosis is that the poor guy has a bunch of laminated  clot in 
the RA. I was called only a few hours until they were going to  cardiovert 
him out of flutter.  Of course, I immediately stopped  that.  The differential 
diagnosis, of course, could be tumor.  I plan  to get a gated cardiac MRA to 
further elucidate the nature of the mass.  I  might consider a transjugular 
biopsy. If possible, I think the  clot needs to be removed and a maze carried out. 
 However, I'm unsure  how to handle the perioperative anticoagulation.  HELP!!
Hal