A 94-year-old female presented to our centre with abdominal pain, nausea, and vomiting. The pain first started about a month prior to presentation and occurred while she was eating, resulting in a 10-pound weight loss. She had a long history of atrial fibrillation and was on warfarin. Her international normalized ratio (INR) had been maintained in the therapeutic range (i.e. 2–3) for most of the time in the past three and half years. The transthoracic echocardiography (TTE) performed about one and a half years ago was significant for moderate mitral stenosis (mean gradient = 6 mm; valve area = 0.83 cm2), diffuse thickening of mitral valve leaflet with restricted opening (rheumatic-like), moderate tricuspid regurgitation, severely dilated left atrium (maximal dimension = 5.4 cm), and preserved left ventricular ejection fraction (55–60%). Her other comorbidities included hypertension, hyperlipidaemia, chronic obstructive pulmonary disease, dementia, and a history of congestive heart failure.
On this admission, her INR was 2.0. Cardiovascular examination was significant for irregularly irregular rhythm and a grade II/VI diastolic murmur best heard at the apex. A computed tomography angiogram (CTA) revealed diffuse atherosclerosis of the aorta, a chronically occluded superior mesenteric artery and left iliac artery system, and a new wedge-shaped splenic infarction. A large mass in the left atrium was also observed on CTA (Panel A). Bedside TTE confirmed a 5 × 4 cm free-floating thrombus (Panel B), behaving like a pinball in the severely dilated left atrium and intermittently obstructing the mitral valve (see Supplementary material online, Video S1). Due to the poor prognosis and the patient’s wish, her family declined surgery, and she died 4 days after admission due to a massive embolic stroke.
A large, mobile thrombus in the left atrium can result in devastating complications. Urgent cardiopulmonary bypass-assisted surgical resection should be recommended to any surgical candidate regardless of symptoms. Postoperatively, chronic anticoagulation and close monitoring are required to prevent a recurrence. Percutaneous vacuum-assisted thrombectomy can be considered for thrombus in the right heart. Although its use in aspirating left heart mass has been reported sporadically, this endovascular approach is not suitable for such a large left atrial thrombus reported in our case. Regarding medical management, apixaban is an accepted alternative prophylactic anticoagulation strategy for atrial fibrillation in a patient who is a non-responder to warfarin.
Supplementary material
Supplementary material is available at European Heart Journal – Case Reports online.
Consent: The patient reported in this case report is deceased. Despite the best efforts of the authors, they are not able to contact the patient’s next-of-kin to obtain consent for publication. Every effort has been made to anonymize the details of this case. This has been discussed with the editors.
Conflicts of interest: None declared.
Funding: None declared.
Supplementary Material
Contributor Information
L Wiley Nifong, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA.
Kanhua Yin, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA.
Michael J Bates, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA.
Benjamin C Degner, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA.
W Douglas Boyd, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA.
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