A 53‐year‐old woman with rheumatic heart disease (having had a Bjork‐Shiley 29 mitral prosthesis and a Braille 31 tricuspid bioprosthesis implanted in 1980 and 1995, respectively), in permanent atrial fibrillation, was electively admitted to our department for redo cardiac surgery. Ten weeks previously she was diagnosed with severe tricuspid stenosis (bioprosthesis degeneration), in New York Heart Association functional class III heart failure and was scheduled for cardiac reintervention. At that time mitral prosthesis function was normal and the left atrium (LA) was free of thrombi at transoesophageal echocardiography (TOE) (video 1; to view video footage visit the Heart website—http://www.heartjnl.com/supplemental).
Three weeks later the patient suffered a gastrointestinal haemorrhage. Anticoagulation was stopped, blood products were administered, her condition stabilised and anticoagulation was resumed, but the international normalised ratio (INR) was not checked thereafter. At current admission she was clinically stable and no embolic events or clinical hints suggestive of LA ball thrombus could be identified. The INR was 1.05. A free‐floating LA thrombus was diagnosed by transthoracic echocardiography (video 2). Mitral prosthesis was normal and the tricuspid bioprosthesis had deteriorated and was severely stenotic. TOE showed the thrombus entering the mitral prosthesis intermittently, being hit by the disc and bouncing back into the LA (panel A, video 3).
At surgery, a 3 × 3× 4 cm free‐floating thrombus (panel B) was removed from the LA and the tricuspid prosthesis was replaced. Recovery was uneventful. This is a very rare case of a large, clinically silent free‐floating LA thrombus formed over a short period of time in a patient with a normal mechanical mitral prosthesis, stressing the importance of appropriate anticoagulation.
(A) Transoesophageal echocardiography showing the free‐floating thrombus in the left atrium (see video 3). (B) The thrombus after its surgical removal from the left atrium.
To view video footage visit the Heart website—http://www.heartjnl.com/supplemental
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