Transient total occlusion of the mitral valve orifice by a free-floating left atrial ball thrombus.

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.     

Left atrial ball thrombus: Echocardiographic features and clinical implications

The echocardiographic features of left atrial ball thrombusassociated with mitral stenosis are reviewed, and some previouslyunpublished cross-sectional echocardiographic findings presented.In one patient who had a large free-floating ball thrombus therewas variation in its echocardiographic appearance; the thrombuswas removed uneventfully at surgery. In another patient whohad a pedunculated but immobile ball thrombus, a stalk was identifiedwhich attached it to the inter-atrial septum; this patient diedsuddenly before surgery could be performed, due to detachmentof the thrombus and obstruction of the mitral valve orifice.Cross-sectional echocardiography is clearly superior to M-modeimaging in the detection of atrial thrombi, and variable appearancesmav help differentiation of thrombus from myxoma. Whether ornot a ball thrombus appears mobile, emergency thrombectomy andmitral valve replacement is indicated, because of the risk ofobstruction of the mitral valve.     

Free-floating left atrial ball thrombus following mitral valve replacement

We report the case of a 51-year-old woman who underwent mitral valve replacement for prolapse with severe regurgitation, depressed ejection fraction, and atrial fibrillation. Two weeks post-operatively, a transesophageal echocardiogram was performed for bacteremia. The patient was found incidentally to have a large free-floating ball thrombus in the left atrium. The patient was managed with anticoagulation because of the high-risk nature of repeat surgery. One month following diagnosis, the patient still had persistent thrombus in the left atrium seen on transthoracic echocardiography despite therapeutic anticoagulation. Free-floating ball thrombus is a rare and dramatic finding seen on echocardiography in patients with mitral valve disease.     

Large free-floating left atrial thrombus with normal mitral valve

Left atrial thrombus in the presence of diseased mitral valve and atrial fibrillation is a well known entity. But it is very rare to occur in the presence of normal mitral valve apparatus. We report the case of a 36 year old female who presented with left atrial ball valve thrombus and normal mitral valve apparatus and underwent surgery. This patient with gangrene of right lower limb came for cardiac evaluation. She had infarct in left middle cerebral artery territory- ten months prior to this admission and was on treatment for infertility. She had atrial fibrillation. Emergency surgery to remove the thrombus should be considered given its potential life threatening embolic nature.     

Free-Floating Ball Thrombus in Left Atrium

Left atrial (LA) ball thrombus is a rare disorder. These ball thrombi are generally associated with mitral stenosis, and the restricted mitral orifice encloses the free-floating thrombus in the LA. There is a potential for fatal systemic emboli or mitral value orifice occlusion that may result in sudden death. We report the case of a patient with tight rheumatic mitral stenosis in whom a ball thrombus was observed to bounce and rebound off the walls of LA on echocardiography. After the patient received anticoagulant therapy for 1 month, the thrombus was not found at surgery.     

Left Atrial Free-Floating Ball Thrombus in a Case of Hyperthrophic Cardiomyopathy

Left atrial free-floating ball thrombus is a rarely seen pathology in the absence or presence of mitral valve disease. This pathologic condition carries high risks of embolic complications and deterioration of hemodynamics. The case reported here is a 34-year-old woman who had been followed-up by another center with the diagnosis of hypertrophic cardiomyopathy (HCM) was admitted to our emergency department in cardiogenic shock due to left atrial free-floating ball thrombus partially obstructed the left ventricular inflow. Emergency surgery was undertaken to remove the ball mass, additionally septal myectomy and mitral valve replacement were performed. Pathologic examination of the mass confirmed the thrombus formation. This rare case of left atrial free floating ball thrombus associated with HCM is presented and current literature is reviewed.     

Eustachian valve thrombus:critical factor in outcome of venous thromboembolism

This case report describes a patient with pulmonary embolism (PE) in whom transesophageal echocardiography showed a thrombus in the right atrium attached to the eustachian valve (EV). The EV is typically absent in the adult, but when present it is considered to be benign. It is an uncommon site for thrombus formation. This patient was treated with systemic anticoagulation.     

Acute heart failure and near-syncope associated with giant left atrial ball thrombus occluding left ventricular inflow tract.

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 x 3.9 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.     

Prosthetic aortic valve thrombosis: To fibrinolyse or not to fibrinolyse? That is the question!

Prosthetic heart valve (PHV) dysfunction is a rare but serious complication whose optimal management may be challenging and requires a multidisciplinary approach. Treatment success ultimately depends on determining the underlying mechanism of valve dysfunction by echocardiography. However, being able to establish the main etiology is not always straightforward. We present a difficult case of obstructive PHV dysfunction and discuss clinical and echocardiographic parameters to help differentiate thrombus from pannus formation.     

Echocardiographic mimicker of thrombus on a mechanical aortic valve prosthesis due to cavitation: A paradoxical phenomenon of pressure recovery

We describe a case of a mass‐like echocardiographic density on a mechanical prosthetic aortic valve. We initially suspected a thrombus vs vegetation on transthoracic echocardiography, but after transesophageal echocardiography, the density was subsequently determined to be cavitation by reviewing the initial images in slow motion.     

Two cases of a free-floating ball thrombus in the left atrium.

A free-floating ball thrombus in the left atrium is an unusual occurrence that may cause fatal systemic emboli or left ventricular inflow obstruction, often resulting in sudden death. The first of 2 cases was a 59-year-old female with mitral stenosis and chronic atrial fibrillation who presented with severe dyspnea. Transthoracic echocardiography revealed a free-floating ball thrombus and emergency thrombectomy and mitral valve replacement were performed successfully. A second thrombus, which was not found at preoperative examination, was attached to the anterior mitral leaflet and may have been the source of the free-floating ball thrombus. The second case was a 79-year-old female with chronic renal failure who underwent mitral valve replacement 11 years prior to admission. She had been dependent on hemodialysis for 10 years, and had suffered several recent transient cerebral ischemic attacks. Computed tomography showed a ring-shaped, high-density area in the left atrium and transthoracic echocardiography revealed a floating ball thrombus in the left atrium. Thrombectomy was performed, but the patient died as a result of postoperative pneumonia 2 months later. Case 2 appears to be the first reported case of a ball thrombus in a hemodialysis patient who had previously undergone mitral valve replacement.     

Free-floating ball thrombus in the left atrium

 Free-floating ball thrombi in the left atrium are rarely seen. They can cause sudden death by occluding the mitral valve. A 47-year-old female patient who showed signs of mitral stenosis during a physical examination and atrial fibrillation by electrocardiography was not administered anticoagulant therapy. On the transthoracic echocardiogram, a stenotic mitral valve and a floating mobile mass were seen inside the large left atrium. This mass was rounded (ball-like), had smooth contours, and occasionally occluded the stenotic mitral valve. The patient underwent emergency surgery to remove the mass, which was later proven to be a thrombus pathologically. Additionally, mitral valve replacement was performed. The importance of anticoagulant therapy for patients with rheumatic mitral stenosis has been emphasized by this case. Received: January 30, 2002 / Accepted: March 23, 2002     

The effect of body position on a free-floating ball thrombus as observed by transesophageal echocardiography

Two cases of free-floating left atrial ball thrombi (FLABT) in association with mitral stenosis were observed by transesophageal echocardiography (TEE). Our report describes the relation between body position and thrombi kinetics. Both cases demonstrated similar kinetics. In the supine and right lateral decubitus positions, the thrombi recoiled from and sometimes became entrapped within the mitral valve. In the sitting and left lateral decubitus positions, the thrombi appeared to be nearly fixed and did not contact with the mitral valve. Our results indicate that the latter two positions prevent thrombi disintegration and incarceration into the mitral valve. Finally, TEE is an extremely useful tool for assessing the safest position for individuals with FLABT.     

Transesophageal echography in the investigation of left atrial ball thrombi. Apropos of a case of migration of a left atrial thrombus

The authors report the case of a pediculated left atrial ball thrombus whose embolisation and ejection through the aortic valve was recorded during transesophageal echocardiography. The value and risks of transesophageal echocardiography for the diagnosis of left atrial masses are reviewed in the light of this case and a review of the literature. The prognosis and therapeutic implications of a left atrial ball thrombus are also described.     

Spontaneous echo contrast on transthoracic echocardiography and left atrial thrombus in rheumatic mitral valve disease patients: A clinicopathologic study

The association of spontaneous echo contrast and thrombus in the left atrium in patients with mitral valve disease is controversial. This study was undertaken to determine whether there is an independent association between spontaneous echo contrast on transthoracic echocardiography (TTE) and intraoperative evidence of left atrial thrombus and to evaluate the clinical implications of spontaneous echo contrast in patients with symptomatic rheumatic mitral valve disease. A total of 255 patients who underwent surgery for rheumatic mitral valve disases were preoperatively evaluated by transthoracic two-dimensional and Doppler echocardiography. Spontaneous echo contrast in the left atrium was carefully sought. The left atrium was carefully searched for evidence of thrombus intraoperatively. The association of spontaneous echo contrast and left atrial thrombus was determined by univariate and multivariate analysis. Of the patients studied, 77 (30%) had left atrial thrombus. Left atrial thrombus was found in 47 and 21 % of patients with and without spontaneous echo contrast, respectively (p < 0.001). Spontaneous echo contrast and atrial fibrillation were found to be the only two independent predictors of left atrial thrombus (odds ratio = 2.16; 95% confidence interval 1.15-4.04 p < 0.05, and odds ratio = 6.98; 95% confidence interval 3.45-14.16, p < 0.001, respectively). It was concluded that there is an independent association between spontaneous echo con trast on TTE and left auial thrombus in patients with mitral valve disease requiring surgical correction. These patients are at high risk for left atrial thrombus and should, therefore, be con sidered for long-term anticoagulation.     

The transesophageal echocardiographic diagnosis of left atrial myxoma simulating a left atrial thrombus in the setting of mitral stenosis.

We report a case of left atrial myxoma simulating a thrombus on transthoracic echocardiography, but correctly diagnosed using transesophageal echocardiography. As this tumor is usually fatal unless surgically resected, a correct diagnosis is essential. Myxomas which do not prolapse between the mitral valve leaflets and coexist with mitral stenosis may be difficult to diagnose accurately using transthoracic echocardiography. The advantages of transesophageal compared with transthoracic echocardiography in the diagnosis of nonclassical left atrial myxoma are discussed.     

Relationship Between Echocardiographic Determinants of Left Atrial Spontaneous Echo Contrast and Thrombus Formation in Patients with Rheumatic Mitral Valve Disease

Spontaneous echo contrast (SEC) may be detected by ultrasonography in environments favoring blood stasis. It is most commonly seen through the use of transesophageal echocardiography in the left atrium of patients with rheumatic mitral valve disease especially in the presence of atrial fibrillation. We studied the predictors of SEC, such as cardiac rhythm, left atrium and left atrial appendage functions, and mitral and pulmonary vein flow parameters, in patients with rheumatic mitral valve disease. The relationship between these parameters and the severity of SEC and appearance of thrombus was evaluated.     

Delineation of an Octopus‐Like Thrombus Attached to the Eustachian Valve

Eustachian valve (EV) is a vestige of the valve of the inferior vena cava which directs the umbilical vein blood through open foramen ovale in fetal life. Following birth it gradually regresses, but it may persist in variable size, shape, and thickness as a functionless and benign structure. However, there are reports suggesting that persistent EV may not be completely innocent. It has been accused of being a predisposing cause of patent foramen ovale and paradoxical embolism and also interfering with transseptal interventional procedures. It may serve as a site of infective vegetations and be mistaken as a tumor or thrombus. In the present case, an octopus‐like thrombus attached to the EV was delineated with the utility of two‐dimensional and real time three‐dimensional transesophageal echocardiography. EV was considered to play an essential role in preventing potential pulmonary embolism.     

The Eustachian valve in pulmonary embolism: rescue or perilous?

This case illustrates the Eustachian valve as an ambiguous entity. By tethering a thrombus the valve prevented a major pulmonary embolism. However, in combination with a patent foramen ovale, it directs the thrombus into the left atrium, creating a threat for systemic embolisms.     

Massive obliterative right heart thrombus presenting with near‐syncope

Intracardiac thrombi are commonly encountered as a complication of a recent myocardial infarction, heart failure, atrial fibrillation, or intracardiac devices. The prevalence of atrial thrombi in the absence of these risk factors is not well‐described, but seems to be low. We present a case of a 51‐year‐old man with a massive mobile thrombus in the right heart extending through the tricuspid valve, diagnosed on echocardiography after presenting with a presyncopal episode.