FREE FLOATING LEFT ATRIAL BALL THROMBUS

Mehmet Ali Özatik^{Alper Uzun}, Omaç Tüfekçioğlu^{Ferit Çiçekçioğlu}

Türkiye Yüksek İhtisas Hospital, Cardiovascular Surgery Department
^*Türkiye Yüksek İhtisas Hospital, Cardiology Department

Abstract

Here we presented the case of a middle aged woman with a free floating left atrial ball thrombus. Patient was admitted to our outpatient clinic with complaints of dyspnea and fatique about a month before her operation. In her transthoracic echocardiography there were mitral stenosis and thrombus which was attached to left atrial wall (1.5x1.1 cm). The rhytm was atrial fibrillation. The patient was decided to be followed by medical treatment. She was readmitted with sudden worsening of symptoms one month later. In the transthoracic and transesophageal echocardiography, free floating left atrial ball thrombus was detected in size of 2.65x2.88 cm. Then, the patient was operated urgently.

Abstract

Free floating left atrial ball thrombus (FFLABT) appears to be a very unusual case. The term Ball thrombus was first applied to this entity by Wood in 1814 who described autopsy findings in a 15 year-old girl with rheumatic mitral stenosis and syncope [1]. Systemic embolization arising from left atrial thrombus is abundantly seen. Occasionally, thrombus larger than mitral valve area can be detached from left atrial wall and can not pass through mitral valve into systemic circulation causig FFLABT. Diagnosis of a FFLABT in the left atrium should lead to urgent surgery because of the high risk of obstructive and embolic complications [2,3]. Here we presented the case of a middle aged woman with FFLABT whom urgent surgical treatment was applied.

Case Presentation

A 45 year-old woman was admitted to our outpatient clinic with complaints of effort dyspnea and fatique in May 2001. In physical examination, there were louded first heart sound, diastolic murmur in mitral area and hepatomegaly. Rhytm was atrial fibrillation. In transthoracic echocardiography (TTE), fibrocalcific mitral stenosis was determined, mitral valve area was 1.1 cm2, transmitral maximum and mean gradient was 14 and 7 mmHg, respectively. Left atrial width was 4.9 cm. Pulmonary artery pressure was 50 mmHg. In TTE, there was thrombus which was attached to left atrial wall (1.5x1.1 cm) (Figure 1). In cardiac catheterization, mitral stenosis with 5 mmHg gradient was determined. Pulmonary artery pressure was 35 mmHg. She was decided to be followed by medical treatment with digitalis, blockers, diüretic and antiagregant agents. But one month later, she was readmitted with worsening of her symptoms. The patient was orthopneic. In the physical examination, there were rales in the lungs bilaterally, pretibial edema and hepatomegaly. In the chest radiography, there was pulmonary congestion. In transesophageal echocardiography (TEE), a FFLABT(2.65x2.88 cm) was visualized (Figure 2). The patient underwent urgent cardiac operation. Mitral valve replacement with 29 no Carbomedics mechanic valve and left atrial thrombectomy were applied. There was no attachment of thrombus in left atrial cavity. Histopathologic examination of specimen was thrombus (Figure 3). She has been discharged on sixth postoperative day uneventfully.

Figure 1. Transthoracic echocardiography of FFLABT in patient's first admission.

Figure 2. Transesophageal echocardigraphy of FFLABT in patient's second admission.

Figure 3. FFLABT after surgical removal from left atrium.

Case Presentation

Discussion

FFLABT appears to be very rare clinically which may cause bad prognosis but treated well when recognized. It is usually a complication of mitral stenosis. Symptomatic presentation is variable. It may be in obstructive or embolic form or both. In obstructive form, partial or total occlusion of mitral valve by FFLABT may cause pulmonary edema, syncope or sudden death. In embolic form, repeated collisions of FFLABT with atrial walls and mitral valve may result in fragmentations and embolizations of small or larger particles to systemic circulation that may cause visceral, lower extremity or mycardial ischemia, and cerebrovascular accident. Diagnosis of a FFLABT of the left atrium should lead to urgent surgery because of the high risk of obstructive and embolic complications [2,3]

Physical findings usually suggest mitral stenosis and, TTE and TEE are diagnostic tools [4]. Transesophogeal echocardio graphy is an useful tool for assessing the safest position for individuals with FFLABT. In the supine and right lateral decubitus positions, the thrombi recoil from and sometimes become entrapped within the mitral valve. In sitting and left lateral decubitus positions, the thrombi appear to be nearly fixed and does not contact with the mitral valve [5]. Murmur can increase or dissappeaer according to position of thrombus in the left atrium [6]. In our case, FFLABT was sitting on mitral valve orifice at the end of diastole and hurled into left atrial cavity by closure movement of mitral valve leaflets.

Sudden worsening of symptoms are probably due to closure of already stenosed mitral valve orifice by FFLABT that is avoiding passage of the blood from left atrium into left ventricle. Patients should undergo surgical treatment urgently.

Discussion

References

1) Wrisley D, Giambartolomei A, Browmlee W. Left atrial ball thrombus: Rewiev of clinical and echocardiographic manifestations with suggestions for management. Am Heart J 1991;122:1784-90.

2) Abacı A, Kabakcı G, Tokgözoğlu L et al. Transient cerebral ischemic attack and left atrial free-floating thrombus: A case report. Clin Cardiol 1998;21:432-4.

3) Matsuyama N, Kodama T, Wada N, et al. Free floating left atrial ball thrombus with recent cardioembolic stroke. Jpn J Thorac Cardiovasc Surg 2002;50:34-6.

4) Alkan M, Yalçn R, Timurkaynak T, et al. Left atrial free floating thrombus diagnosis by two dimensional and M-mode echocardiography. Japanese Heart J 1995;36:399-404.

5) Miyamoto S, Hadama T, Mori Y. The effect of body position on a free-floating ball thrombus as observed by transesophageal echocardiography. Clin Cardiol 1995;18:535-8.

6) Mutlu H, Küçükoğlu S, Ökçün B, et al Mitral stenozlu bir olguda sol atriyumda serbest dolaşan trombus. Cerrahpaşa J Med 1999;30:184-6.

References

Keywords : Left atrium, ball thrombus, mitral stenosis

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