A Case of Embolism due to a Floating Thrombus Migrating from the Left Atrial Appendage to the Ostium of the Celiac Artery

Abstract

The present case was a 70 year-old dialysis patient who had experienced a prior cerebral infarction following atrial fibrillation. Her shunt suddenly occluded during dialysis, and she was transferred to our hospital. Transesophageal echocardiography revealed a floating, ball-like thrombus in the left atrial appendage (LAA). After thrombectomy in the shunt, acute thrombi were extracted. Despite anticoagulant therapy, the ball-like thrombus in the LAA did not dissipate and instead continued to enlarge. We planned surgical intervention involving a left atrial appendectomy without cardiopulmonary bypass through a left thoracotomy. However, her thrombus disappeared out of the LAA when she was intubated in the operating room. Her surgery was, therefore, stopped, and extubation was carried out. A computed tomography (CT) scan showed that the embolism had moved to the ostium of the celiac artery. Incidentally, this celiac artery had already been obstructed, and her inferior mesenteric artery had been the main supply of blood flow to the intestine, explaining why she had not developed intestinal ischemia. We continued anticoagulant therapy with warfarin. Follow-up CT studies were conducted at the outpatient clinic. However, the patient died due to a wide cerebral infarction before the 6-month checkup.

Mobile Left Atrial Mass-Clot or Left Atrial Myxoma

“…The differential diagnosis for an intra-cavitary cardiac mass includes thrombus, myxoma, lipoma and nonmyxomatous neoplasm [7,8]. Among them, cardiac myxoma is the most common benign primary tumor of the heart and generally found in the LA.…”

“…Other intra-cardiac masses such as lipoma or non-myxomatous neoplasm are rare. TEE is the extensive diagnostic tool to investigate suspected intra-cardiac mass involving the LA [8] and histopathological examination is gold standard for diagnosis of myxoma [9,10].…”

Mobile left atrial round mass free floating in mitral regurgitation flow mimicking a whale spray

“…A left atrial mass may result in sudden circulatory collapse 1. Transoesophageal echocardiography imaging allows unique visualisation of masses and determination of size, shape, motion and spatial orientation within the left atrium 2. Surgical removal of a mobile left atrial mass should be performed before the occurrence of a fatal embolism.…”