European Journal of Echocardiography 2008 9(1):86-87; doi:10.1016/j.euje.2007.02.003
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org.
Acute heart failure and near-syncope associated with giant left atrial ball thrombus occluding left ventricular inflow tract
Kenan Yalta*,
Ahmet Yilmaz,
Okan Onur Turgut,
Mehmet Birhan Yilmaz,
Filiz Karadas,
Gokhan Bektasoglu and
Izzet Tandogan
Department of Cardiology, Cumhuriyet University, Sivas 58100, Turkey
Received 28 December 2006; accepted after revision 4 February 2007; online publish-ahead-of-print 22 March 2007.
* Corresponding author. Tel: +90 5056579856. E-mail address: kyalta{at}gmail.com
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Abstract
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A 70-year-old female patient was admitted to our department
with symptoms and signs of acute heart failure and near syncope.
After hospitalization, both transthoracic echocardiography (TTE)
and subsequent transesophageal echocardiography (TEE) demonstrated
a giant (4.9
x3.9 cm) mobile, irregular, bright left atrial mass
consistent with left atrial ball thrombus (LABT).The mass was
found to occlude the left ventricular inflow tract (LVIT) above
the mitral orifice (supravalvular) in the presence of normal
mitral leaflets. After emergent surgical excision, the pathology
of the left atrial mass was found to be consistent with thrombus.
The case presented here suffered acute diastolic heart failure
and near-syncope due to obstruction of the LVIT above the mitral
orifice by a giant LABT.
Keywords: Left atrial ball thrombus; Acute heart failure; Near-syncope
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Case report
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A 70-year-old female patient was admitted to our department
with symptoms and signs of acute heart failure (dyspnea, bilateral
pulmonary rales, etc.) and near-syncope (visual blurring, hypotension,
etc.). On physical examination, a loud diastolic murmur at cardiac
apex and hypotension (70/50 mmHg) with a mild degree of irregular
tachycardia were present. In the history, the symptoms of ortopnea
and slight visual blurring had started 4 days before admission.
There was no history of any embolic event. Electrocardiogram
(ECG) demonstrated the pattern of atrial fibrillation (AF) with
a fast ventricular rate (110/min). After hospitalization, transthoracic
echocardiography (TTE) and subsequent transesophageal echocardiography
(TEE) (
Figure 1A and
B) demonstrated a giant (4.9
x3.9 cm)
mobile, irregular, bright left atrial mass consistent with thrombus.
The mass was found to occupy a great portion of the left atrial
cavity and occlude LVIT above the mitral orifice with a peak
diastolic gradient of 22 mmHg. The mitral leaflets were found
to be minimally thickened with a mild degree of mitral regurgitation
but with no signs of stenosis. The right ventricular peak systolic
pressure was 65 mmHg (across the mild tricuspid regurgitation).
There were no signs of pulmonary venous obstruction and thrombus
in the left atrial appendage on TEE. The other echocardiographic
findings were found to be normal. The emergent surgical excision
was performed. The pathology of the left atrial mass was found
to be consistent with thrombus. After the surgery, the TTE demonstrated
a peak right ventricular pressure of 35 mmHg without any residual
supravalvular gradient.
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Figure 1 (A) The image of the giant left atrial ball thrombus (LABT) on transesophageal echocardiography (TEE), in the two-chamber view. LV, left ventricle. (B) The image of the giant left atrial ball thrombus (LABT) on transesophageal echocardiography (TEE), in the bi-caval view. RA, right atrium.
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Discussion
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Clots within the body of the left atrial cavity may be encountered
particularly due to AF. Peripheric embolization is the most
common manifestation of left atrial thrombi. Unlike myxomas,
obstruction due to left atrial thrombi is a rare event, and
when present, is usually due to the obstruction of pulmonary
veins usually detected with TEE.
1 In the present case, there
was no sign of pulmonary venous, but LVIT obstruction above
the mitral orifice, on TEE. An unattached, freely moving clot
within the left atrium, as in this case, is called a left atrial
ball thrombus (LABT).
2 These clots are rarely encountered and
may be fatal in case of embolization or obstruction.
3
In conclusion, the case presented here suffered acute diastolic heart failure and near-syncope due to obstruction of the LVIT above the mitral orifice by a giant LABT.
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References
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- Samdarshi TE, Morrow WR, Helmcke FR, Nanda NC, Bargeron LM Jr, Pacifico AD. Assesment of pulmonary vein stenosis by transesophageal echocardiography. Am Heart J (1991) 122:1495.[CrossRef][Web of Science][Medline]
- Furukawa K, Katsume H, Matsukubo H, Inoue D. Echocardiographic findings of floating thrombus in left atrium. Br Heart J (1980) 44:599.[Abstract/Free Full Text]
- Alyan O, Ozdemir O, Kacmaz F, Ozeke O, Tufekcioglu O. Transient total occlusion of the mitral valve orifice by a free-floating left atrial ball thrombus. Eur J Echocardiogr (2006) 6:420–2.
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Abstract
Case report