A Case with Recurrent Free-Floating Ball Thrombi in Left Atrium

Abstract

Patient: Female, 74Final Diagnosis: Left atrial ball thrombusSymptoms: Abdominal discomfort • dyspneaMedication: —Clinical Procedure: —Specialty: CardiologyObjective:Rare diseaseBackground:A free-floating ball thrombus in the left atrium is a rare clinical condition. However, the diagnosis of this condition has been facilitated by the advent and development of echocardiography and multi-detector row computed tomography (MDCT) and several cases have been reported.Case Report:We report a case of a 75-year-old woman who had recurrent giant spherical thrombi in the left atrium. She was diagnosed with chronic atrial fibrillation at 52 years of age. A pacemaker implantation was performed at 54 years of age because of a complete atrioventricular block; and mitral valve replacement was performed for severe mitral regurgitation at 62 years of age. She had a history of cerebral infarction and she was under treatment for chronic heart failure.Despite intensive anticoagulant therapy, she developed ball thrombi in the left atrium three times in six months. During hospitalization for acute myocardial infarction treated with percutaneous catheter intervention, transthoracic echocardiography and computed tomography (CT) revealed a free-floating giant spherical thrombus in the left atrium. She was treated with intensive anticoagulation therapy and the left atrial ball thrombus disappeared; however, two ball thrombi in the left atrium and left atrial appendage recurred after three months. Surgical removal of the thrombi and closure of the left atrial appendage were performed. Unfortunately, a ball thrombus in the left atrium recurred again after a further three months.Conclusions:The present case highlights the difficulty of treating refractory thrombi in the left atrium.

Left Atrial Ball-Shaped Thrombus with Concomitant Biatrial Appendage Thrombi in a Patient with Prior Mitral Valve Replacement

“…Although similar cases were abundantly described [4–11], to the best of our knowledge, a free-floating ball-shaped thrombus with coexisting biatrial appendage thrombi imaged on echocardiography was the first reported case. In the only relevant report, Yoshioka et al introduced a case of left atrial ball-shaped thrombus in conjunction with left atrial appendage thrombus [11]. For our case, in addition, other than anatomical and functional abnormalities of the left atrium, a low-output state associated with stenotic prosthetic valve might facilitate thrombosis in the appendages.…”

“…Free-floating ball-shaped thrombus in the left atrium is a rare finding among patients with mitral valve disease with or without a history of valve replacement surgery [3–8]. This type of thrombus was reported to form in the absence of valve disease and also to recur despite adequate anticoagulation [10, 11]. The precise mechanism behind the occurrence of a free-floating ball-shaped thrombus remains uncertain.…”

“…Based on her clinical history (long-standing atrial fibrillation and postprosthetic valve implantation), situations (discontinued anticoagulation and coexistence of appendage thrombi), and previous reports on similar cases [4–11], the ball-shaped free-floating mass was implied as a thrombus. Although a surgical procedure for the atrial thrombi was considered, the patient was determined to be managed conservatively with therapeutic anticoagulation, because she was diagnosed as having terminal cancer and thus in a malnourished condition.…”

“…It was first reported by Wood in 1814, who described an autopsy record in a 15-year-old girl with rheumatic mitral stenosis presenting recurrent syncope [3]. Since then, there have been a volume of reports on this entity particularly in the echocardiography era [4–11]. We herein reported a 67-year-old woman with prior mitral valve replacement surgery in whom multiple atrial thrombi, including a free-floating ball-shaped thrombus, were found on echocardiography.…”

Left atrial ball thrombus: a particularly emboligenous anatomical shape

“…It is speculated that a fixed thrombus initially forms in the left atrial appendage or the left atrial wall [6] . Afterwards, it grows into a round shape, followed by disconnection of the pedicle between the thrombus and the atrial wall [7] . Wall-adherent thrombi can detach and float freely [8] .…”