Free floating ball thrombus of left atrium developing late after closed mitral commissurotomy - a case report

Left atrial ball thrombus is very rare entity and it is even rare to find a large free floating ball thrombus of left atrium in a post-operative patient. Thrombus of left atrium usually occurs in atrial fibrillation or in mitral valve stenosis. Here we are presenting a case of large ball thrombus of left atrium in a patient who underwent closed mitral commissurotomy 21 years back. A 50 years old female patient was admitted with history of breathlessness, palpitation and cough of one month duration. She was doing well after mitral valve commissurotomy. Her pre-operative trans-thoracic echocardiography showed a left atrial thrombus and severe mitral stenosis with valvular area of 0.7 cm² and atrial fibrillation. Per-operative trans-oesophageal echocardiography showed a large free floating ball thrombus of left atrium. She underwent removal of left atrial thrombus and mitral valve replacement using Sorin Bicarbon valve.     

Acute post-cardiopulmonary bypass left atrial thrombosis after mitral valvuloplasty and left atrial thrombectomy

A patient with mitral stenosis and multiple left atrial thrombi underwent valvuloplasty and thrombectomy. While closing the sternum after completing the cardiopulmonary bypass, a new left atrial thrombus was detected by transesophageal echocardiography. We used heparin for the prevention of new thrombus formation and closed the wound after meticulous bleeding control. Three months later, there was no residual thrombus in the left atrium according to the echocardiographic study.     

Life-threatening pulmonary embolism associated with a thrombus straddling a patent foramen ovale: report of a case

BACKGROUND AND AIM: A biatrial thrombus straddling a patent foramen ovale (PFO) is rare. The optimal management is controversial. This report offers an additional report and brief review of the literature. CASE REPORT: A 72-year-old female presented with paroxysmal dyspnea. Transthoracic echocardiography showed distended right heart cavities, pulmonary artery hypertension, and a thrombus in the right atrium passing through the PFO into the left atrium. Urgent surgical embolectomy confirmed an 11.5 cm serpentine biatrial thrombus and allowed PFO closure and bilateral pulmonary embolectomy. Postoperative recovery was uneventful. CONCLUSIONS: The risk of systemic embolization during thrombolytic or heparin treatment for biatrial thrombus makes most authors recommend surgical or interventional thrombectomy and PFO closure. Given the limited number of cases, there is no evidence that any of the treatment strategies provide a better survival.     

Acute early failure of a bioprosthesis after mitral valve replacement with completely preserved annuloventricular continuity

We report a case of acute early bioprosthetic failure after mitral valve replacement with completely preserved annuloventricular continuity. A 77-year-old man with left ventricular dysfunction underwent double valve replacement with Carpentier-Edwards pericardial bioprostheses. Routine postoperative echocardiography revealed 1.4 cm² of estimated mitral valve area, and computed tomography revealed a large thrombus in the left atrium. Transesophageal echocardiography showed a restricted opening of the bioprosthetic leaflets. After a month of strict anticoagulation therapy, cusp mobility improved, with a calculated mitral valve area of 3.5 cm²; and the left atrial thrombus had almost disappeared 2 months after initiation of therapeutic anticoagulation. Surgeons should be watchful for bioprosthetic thrombosis in patients with left ventricular dysfunction who undergo mitral valve replacement with a preserved mitral subvalvular apparatus.     

Pulmonary thromboembolism in a patient with rheumatic mitral valve stenosis: a fortuitous association?

In this case report, we illustrate our experience with a patient simultaneously suffering from rheumatic mitral valve stenosis and pulmonary thromboembolism who successfully underwent mitral valve replacement and pulmonary thromboendarterectomy. Physical examination and transthoracic echocardiography revealed mitral stenosis, atrial fibrillation, and a large thrombus in the left atrium. The preoperative workup led to the diagnosis of pulmonary thromboembolism. This case emphasizes the importance of preoperative evaluation for pulmonary thromboembolism in symptomatic patients with mitral valve stenosis and atrial fibrillation.     

Coincidence of free-floating thrombus in the aortic arch, severe mitral stenosis, and left atrial appendage clot

We describe the surgical management of a free-floating thrombus in the aortic arch in a patient with severe mitral stenosis, a left atrial appendage (LAA) clot, and an iliac artery thrombus. A 60-year-old woman complaining of dyspnea and pain in her right leg was referred to our multidisciplinary clinic. After a brief history was taken, an electrocardiography evaluation showed atrial fibrillation. Color Doppler sonography of the lower limb arteries showed decreased blood flow in distal branches of the internal iliac artery of the right leg. Transthoracic and transesophageal echocardiography evaluations revealed severe mitral stenosis, a large LAA clot, and a large mobile mass (2 × 1.5 × 1.5 cm) in the distal aortic arch. Additional investigations with computed tomographic angiography revealed that the thrombus extended from the aortic arch to the subclavian artery. Another bulky thrombus in the right iliac artery was also found. Given this complicated medical situation, emergency cardiac surgery was performed, and the clot was removed. The stenotic mitral valve was replaced with a prosthetic valve, The LAA was closed after clot removal, and the bulky thrombus was extracted from the right iliac artery. Transesophageal echocardiographic data were obtained postoperatively, and the patient's course in the intensive care unit was favorable. She was discharged from the hospital in good condition on warfarin, digoxin, aspirin, and metoprolol.     

Mitral stenosis with free-floating left atrial thrombus and recurrent systemic embolisation. A case report

A 64-year-old white woman with moderately severe rheumatic mitral stenosis complicated by atrial fibrillation and recurrent systemic embolisation to the brain was found at operation to have a large 'free-floating' left atrial thrombus, as well as multiple left atrial appendage thrombi. These had not been detected by echocardiography. She also had significantly reduced left ventricular contractility on cine angiography, and right coronary artery atherosclerosis. She underwent successful mitral valve replacement and excision of the left atrial appendage.     

Mitral valve prosthetic endocarditis: development of left ventricular-coronary sinus fistula following replacement

We report the history and course of a patient in whom a left ventricular-coronary sinus fistula developed following mitral valve replacement due to prosthetic endocarditis. Six months after the intervention the patient suddenly presented with deterioration of her symptoms, holosystolic murmur and signs of congestive heart failure. Transesophageal echocardiography showed a left-to-right shunt but did not show its exact location. At surgery, exploration of the right atrium revealed a left ventricular-coronary sinus communication due to discontinuation of the left ventricular free wall next to the coronary sinus; repair of the defect was successfully performed by direct suture. The postoperative course was uneventful and the patient recovered quickly. This case is reported to stress that debridement of the mitral annulus and removal of an old prosthesis must be very carefully performed and to facilitate the diagnosis of this rate but severe complication of repeated mitral valve replacement.     

Free-floating giant left atrial ball thrombus with aortic valve disease--a rare entity and a near miss

Large left atrial mural thrombi in the absence of mitral valve stenosis have been reported rarely in the literature. It is even rarer without history of atrial fibrillation (AF). These masses can cause systemic embolization and sudden circulatory collapse when they obstruct the mitral valve. We are presenting a case of giant, free floating ball thrombus, detected after aortic valve replacement for mixed aortic valve disease. It was found immediately before separation from cardiopulmonary bypass by transoesophageal echocardiography and was successfully removed. A ball thrombus without mitral valve disease and AF with aortic valve disease is not yet reported in the literature.     

Floating ball thrombus in the left atrium with mitral stenosis

We report, a case of a floating ball thrombus in the left atrium with mitral stenosis in a 76-year-old woman. The patient had been followed-up at our hospital due to mitral valve stenosis for several years, and was recognized to have atrial fibrillation and a left atrial mural thrombus by echocardiography. She was admitted to our hospital for right cerebral infarction. Echocardiography showed a floating ball thrombus in the left atrium. After the treatment of cerebral infarction, she was referred to cardiac surgery, and a semi-urgent operation was performed. Removal of the ball thrombus and mitral valve replacement were performed simultaneously. The thrombus was single round, soft, relatively smooth surfaced, and about 30×30×30 mm in diameter. The postoperative course was uneventful. Left atrial ball thrombus appears to be uncommon. This is a rare case, in which it was documented that a pre-existing left atrial mural thrombus was thought to drop off spontaneously, to be a cerebral embolic source, and to develop into a ball thrombus in the left atrium.     

Mitral valve stenosis associated with a floating ball thrombus in the left atrium; report of a case

A floating ball thrombus in the left atrium is relatively a rare case. A 70 year-old female patient who showed a symptom of heart failure was admitted to our hospital. By echocardiography, the mass in the dilated left atrium was appeared to be a floating ball thrombus, and the patient was diagnosed to be mitral valve stenosis. Following the treatment of heart failure, the patient underwent mitral valve replacement and the ball thrombus was successfully removed. Because of the high risk of sudden death with strangulated ball thrombus and systemic embolization, surgical removal of the ball thrombus should be done immediately after the diagnosis was established.     

Acute left atrial thrombus causing cardiogenic shock following mitral valve replacement: Report of a case

We report herein the rare case of a 53-year-old woman who developed cardiogenic shock due to an acute left atrial thrombus following replacement of the mitral valve. A definitive diagnosis was not able to be made using precordial echocardiography because of the broad, flat shape of the thrombus; however, transesophageal echocardiography imaged the thrombus in detail. The patient was initially stabilized by percutaneous cardiopulmonary support after which a thrombectomy was successfully performed.     

Surgical pulmonary embolectomy for submassive pulmonary embolism: a case report and review of the literature

We present an interesting case of recurrent syncope which was found to be submassive Pulmonary Embolism (PE) with right atrial thrombus. Patient underwent successful surgical pulmonary embolectomy with removal of right atrial thrombus. Follow-up computed tomography revealed bilateral patent pulmonary circulation with normal right ventricle function and pulmonary artery pressure on echocardiography. We also reviewed the literature for the patients operated for submassive pulmonary embolism and their results.     

A case report of successful mitral valve replacement for congenital mitral stenosis associated with coarctation of the aorta and ventricular septal defect

A 5-month-old infant with coarctation of the aorta, ventricular septal defect and mitral stenosis known as "Shone's anomaly" is presented. He underwent the repair of coarctation of the aorta by means of the extended aortic arch anastomosis and banding of the pulmonary trunk at 1 month of age and the patch closure of ventricular septal defect and debanding of the pulmonary trunk at 3 months of age in our institution. About 2 months after second surgery, he had been admitted to our institution due to developing tachypnea and he needed the support of mechanical ventilation. The chest X-ray showed pulmonary congestion and the echocardiography revealed only one papillary muscle of mitral valve and pressure gradient about 30 mmHg through mitral valve. Mitral stenosis due to parachute mitral valve was suspected and he was subjected to an emergent surgery. Initially we performed mitral valve repair for parachute mitral valve but echocardiography during the surgery revealed moderate grade of mitral regurgitation and a hemodynamics was not satisfactory. Eventually mitral valve replacement was successfully done with Carbo-Medics mechanical valve (19 mm in diameter) in the position of left atrial wall because his mitral annulus was so small as 10 mm in diameter. The postoperative course was uneventful and the patient has been doing well.     

Acute coronary embolism without valve thrombosis in a patient with a prosthetic mitral valve--successful percutaneous coronary intervention: a case report

We present a 44-year-old female patient with anterior myocardial infarction caused by embolization from mitral valve prosthesis due to inadequate anticoagulation. The patient underwent a cardiac catheterization within the 1st hour of arrival. The angiography showed total occlusion of the left anterior descending coronary artery after the second diagonal branch. Percutaneous transluminal coronary angioplasty and stenting were performed, and coronary artery perfusion was restored. The pain disappeared completely immediately after this intervention. Transthoracic echocardiography shortly after this intervention showed normal prosthetic valve function and no thrombus. Transesophageal echocardiography performed 2 days later revealed no thrombus at the prosthetic valve. In conclusion, this case demonstrated that coronary embolism may occur even without prosthetic valve thrombus or dysfunction with suboptimal International Normalized Ratio levels, and can be successfully treated with percutaneous transluminal coronary angioplasty and stenting.     

Early degeneration of a bioprosthetic mitral valve complicated by a large left atrial thrombus

The authors report the case of a patient with symptomatic early bioprosthetic mitral valve deterioration in the setting of calcium supplementation. This was further complicated by a large left atrial thrombus despite supratherapeutic anticoagulation and a previously oversewn left atrial appendage. As mechanical valves are less predisposed to calcification in comparison with bioprosthetic implants, the patient underwent a mechanical mitral valve replacement in addition to a left atrial thrombectomy.     

Mitral regurgitation due to anomalous attachment of chordae tendineae to the left atrial wall

A 47-year-old female admitted to our hospital with exertional dyspnea and cerebral thromboembolism. There was no history of rheumatic fever. The chest roentgenogram showed marked cardiomegaly with pulmonary congestion. Ultrasound cardiogram showed mitral valve incompetence and abnormal echo shadow in the left atrium. Left ventriculogram revealed grade 3 mitral regurgitation. At operation, a 5-cm anomalous chordae tendineae was attached to the left atrial wall through the mitral orifice. The mitral valve showed thickening of the leaflets and fusion of the posterior commissure. The mitral valve was replaced with a mechanical prosthesis. The patient has been doing well after her surgery.     

Akute perioperative Mitralklappeninsuffizienz

This report describes the case of a 59-year-old man who was scheduled for general anesthesia with propofol, sufentanil and sevoflurane for removal of a metal implant. The patient was classified as American Society of Anesthesiologists (ASA) II status because of an asymptomatic mitral valve prolapse and medically treated arterial hypertension. During induction of narcosis a pulsoxymetrically measured inadequate increase in oxygen saturation after preoxygenation was noticed and a moderate respiratory obstruction occurred intraoperatively, but anesthesia was uneventfully completed and the patient was extubated. However, 3 h later the patient developed severe dyspnea, hypoxia, tachycardia and arterial hypotension. Physical examination revealed a new grade 4/6 systolic murmur radiating to the axilla and X-ray showed bilateral pulmonary edema. Neither electrocardiographic nor biochemical manifestations of acute myocardial infarction were identified but transthoracic echocardiography revealed fluttering of the posterior leaflet of the mitral valve with grade III regurgitation and dilation of the left atrium. Coronary angiography was normal and left ventriculography confirmed severe mitral regurgitation. Mitral valve repair was successfully performed 22 h after presentation of symptoms. Mitral regurgitation is a common finding on echocardiography, seen to some degree in over 75% of the population. The etiology of mitral valve insufficiency which can be caused by pathologic changes of one or more of the components of the mitral valve, including the leaflets, annulus, chordae tendineae, papillary muscles, or by abnormalities of the surrounding left ventricle and/or atrium are discussed. Rupture of mitral chordae tendineae is infrequent and causes acute hemodynamic deterioration and needs corrective surgery. Valve replacement should be performed only if mitral valve repair is not possible. Echocardiography is an invaluable tool in determining the severity of regurgitation, the integrity of the mitral valve apparatus, the extent of left ventricular enlargement, and the ejection fraction. Acute mitral valve regurgitation caused by a rupture of chordae tendineae should be considered in the differential diagnosis of perioperative acute pulmonary edema.     

Free-floating left atrial ball thrombus without mitral valve disease

Reports of left atrial ball thrombus without mitral valve disease are few. We experienced a case of free-floating left atrial ball thrombus that developed in a short period in a patient with atrial fibrillation and dilated left atrium but intact mitral valve. Surgical removal of the thrombus was performed. It was presumed that atrial fibrillation and enlarged left atrium were the contributory factors to thrombus development.     

On pump beating heart mitral valve repair without aortic cross-clamp for low ejection fraction ischemic mitral regurgitation after coronary artery bypass grafting; report of a case

A 59-year-old male with congestive heart failure caused by impaired left ventricular function after coronary artery bypass grafting (CABG) was referred to our hospital, and massive ischemic mitral regurgitation was detected by echocardiography. This patient underwent on-pump beating-heart mitral valve repair without aortic cross-clamp successfully through right thoracotomy. Postoperative echocardiography revealed no mitral regurgitation. The patient recovered uneventfully and was discharged on the 17th postoperative day. At 6th month after the operation, he is well without mitral regurgitation.