J Thorac Cardiovasc Surg 2008;136:1374-1376
© 2008 The American Association for Thoracic Surgery
Giant left atrial thrombus with mechanical compromise of the mitral valve
Andres Beiras-Fernandez, MDa,*,
Patrick Moehnle, MDb,
Ingo Kaczmarek, MDa,
Florian Weis, MDb,
Bruno Reichart, MDa,
Calin Vicol, MDa
a Department of Cardiac Surgery, Grosshadern University Hospital, Munich, Germany
b Department of Anesthesiology, Grosshadern University Hospital, Munich, Germany
Received for publication November 4, 2007; revisions received December 20, 2007; accepted for publication December 22, 2007.
* Address for reprints: Andres Beiras-Fernandez, MD, Department of Cardiac Surgery, Grosshadern University Hospital, Marchioninistrasse 15, 81377 Munich, Germany. (Email: abeiras{at}med.uni-muenchen.de).
Free-floating giant thrombus is a rare and severe finding observed occasionally in patients with atrial fibrillation and concomitant mitral valve disease.1
Herein, we report the case of a 76-year-old woman with acute heart failure and lung edema resulting from a giant left atrial thrombus that mechanically compromised the mitral valve.
Clinical Summary
A 76-year-old woman with a record of mitral stenosis was referred to our department because of acute respiratory insufficiency and cardiogenic shock. The electrocardiogram showed atrial fibrillation. Chest radiograph showed massive pulmonary edema and an enlarged heart silhouette. Multislice computed heart tomography showed the presence of intracavitary masses in the enlarged left atrium and confirmed the absence of coronary disease (Figure 1, A and B).
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Figure 1. Computed tomographic study of thorax showed an enlarged left atrium containing a giant thrombus (70 x 60 mm) attached to the lateral wall (A), as well as a second one (35 x 30 mm) compromising the mitral valve (B).
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Transesophageal echocardiography showed a dilated left atrium (95 x 80 mm) and severe mitral valve insufficiency, as well as confirming the presence of two thrombi. The larger one was an 80 x 65-mm free-floating ball thrombus in the middle of left atrium (Figure 2, A) and the second one had a hooklike form (40 x 20 mm; Figure 2, B), which caused intermittent occlusion of the mitral valve and penetrated in the left ventricle.
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Figure 2. Transesophageal echocardiography revealed a giant ball thrombus attached to the free left atrium wall (A). Another thrombus was highly mobile and prolapsed through the damaged mitral valve into the left ventricle (B). Macroscopically, a massive ball thrombus (70 x 60 x 50 mm; C) and a second thrombus (35 x 35 x 7 mm; C) with a hooklike form could be observed after surgical resection.
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The patient immediately underwent cardiopulmonary bypass surgery. The left atrium was opened and both thrombi were dissected, removed, and sent for pathologic examination, which revealed chronic thrombus formation. The mitral valve was severely damaged and had to be replaced with a biological prosthesis (Mosaic 29 mm; Medtronic GmbH, Duesseldorf, Germany). The patient was uneventfully weaned off cardiopulmonary bypass. The postoperative period presented no complications and the patient was discharged receiving anticoagulation therapy with phenprocoumon after 10 days. Histopathologic evaluation revealed macroscopically a massive thrombus (70 x 60 x 50 mm) formed on the left atrial free wall, probably because of impaired atrial flow in the setting of a pre-existing mitral valve stenosis and persistent atrial fibrillation (Figure 2, C). A second thrombus (35 x 35 x 7 mm) with a hooklike form was formed on the basis of the first one and penetrated through the mitral valve in the left ventricle (Figure 2, C).
Discussion
Mitral valve disease, especially mitral valve stenosis and atrial fibrillation, are factors leading to formation of intra-atrial thrombi. Free-floating thrombi are occasionally seen and may lead to embolic complications.1 Transesophageal echocardiography has been recommended as the best diagnostic tool for the detection of left atrial thrombi and also for guiding further therapy designed to reduce the thromboembolic risk.2 Furthermore, multislice computed heart tomography not only provides information about the coronary status of the patient but also allows evaluating the compromise of the mitral valve. Mechanical obstruction of the mitral valve without preliminary symptoms is a rare and severe complication.3 However, it should be suspected in patients with cardiogenic shock and pulmonary edema in the presence of atrial fibrillation and mitral valve disease, especially mitral stenosis. In our patient, previous mitral stenosis was aggravated by a thrombus penetrating the left ventricle, which caused mechanical mitral insufficiency. Surgical removal of the thrombi with simultaneous treatment of the underlying cause, in this case replacement of the mitral valve, and subsequent anticoagulation is the therapy of choice.4,5
References
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