European Journal of Echocardiography 2006 7(6):420-422; doi:10.1016/j.euje.2005.12.006
Copyright © 2005, The European Society of Cardiology
Transient total occlusion of the mitral valve orifice by a free-floating left atrial ball thrombus
Omer Alyan*,
Ozcan Ozdemir,
Fehmi Kacmaz,
Ozcan Ozeke and
Omaç Tufekcioglu
Türkiye Yüksek Ihtisas Hospital, Cardiology Clinics, Ankara, Turkey
Received 21 September 2005; received in revised form 13 November 2005; accepted after revision 4 December 2005.
* Corresponding author. Ilkyerlesim mahallesi Sayginlar Sitesi, No: C3/4, Batikent 06370, Ankara, Turkey. Tel.: +90 35 27780922. droalyan{at}yahoo.com
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Abstract
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In patients with mitral stenosis (MS), a free-floating ball
thrombus in the left atrium (LA) is a very rare clinical manifestation,
but has potentially catastrophic consequences such as fatal
systemic emboli or total obstruction of the narrowed mitral
valve orifice, often resulting in sudden death. In this report,
we demonstrated a free-floating ball thrombus within the LA
cavity and transient complete occlusion of blood flow through
the stenotic mitral valve by transthoracic echocardiography.
Awareness of the possibility of such an entity, early diagnosis
and treatment may prevent significant morbidity and mortality.
Keywords: Mitral stenosis; Free-floating ball thrombus
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Introduction
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A free-floating thrombus in the left atrium (LA) in mitral stenosis
(MS) is very rare and has potentially catastrophic consequences.
1 Total obstruction of the narrowed mitral valve orifice may cause
syncope and/or pulmonary congestion.
2 Fragmentation and systemic
embolization may produce ischemia and/or infarction of peripheral
organs. When a ball thrombus is suspected on clinical grounds,
transthoracic echocardiography should be performed without any
delay.
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Case
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A 67-year-old woman was admitted to our hospital with paroxysmal
severe dyspnea, orthopnea, palpitations, peripheral thrombo-embolism
in the right leg and syncopal attacks, which started four days
before admission. The patient was in atrial fibrillation (AF)
(heart rate=120 beats/min), and had never received any drug
for anticoagulation or rhythm control. The first heart sound
was loud, and there was an opening snap, and a loud apical mid-diastolic
murmur changing by position of the patient. The chest X-ray
showed cardiomegaly, pulmonary venous congestion and dilated
pulmonary arteries. Transthoracic echocardiography showed the
stenotic rheumatic mitral valve (mitral valve area=1.4cm
2, calculated
by pressure half-time method), normal left ventricular dimensions
and systolic functions and a 3.8
x3.5cm free-floating ball thrombus
in the LA (
Fig. 1A and B). The thrombus caused intermittent
complete occlusion of the stenotic mitral valve transiently.
The absence of flow through the mitral valve was confirmed by
M-mode color Doppler image (
Fig. 2). The patient subsequently
underwent urgent cardiac operation for removal of free-floating
thrombus from the left atrium and histologic examination proved
that it was a thrombus.
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Figure 1 (A) and (B) Free-floating ball thrombus in the left atrium and rheumatic mitral valve by 2-dimensional transthoracic echocardiography. LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle.
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References
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- Blanche C., Chanx A., Kass R.M., Helfentein J., Sugarman G. Free-floating ball thrombus in the left atrium after mitral valve replacement: successful surgical management. Ann Thorac Surg (1985) 39:566–567.[Abstract]
- Wrisley D., Giambartolomei A., Lee I., Brownlee W. Left atrial ball thrombus: review of clinical and echocardiographic manifestations with suggestions for management. Am Heart J (1991) 121:1789–1790.
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Abstract
Introduction