Left atrial appendage thrombus in a patient in sinus rhythm with endocarditis and a severe aortic valve insufficiency

Abstract

A 66-year-old woman with recently diagnosed monoclonal gammapathy of uncertain significance and no previous cardiac history presented to a tertiary care centre with confusion, aphasia, incontinence and right-sided weakness.One month earlier, she had been admitted to the intensive care unit with a diagnosis of sepsis. At the time, blood cultures had grown Hemophilus influenzae in one of two vials. She received a two-week course of intravenous antibiotics (ampicillin, metronidazole and ciprofloxacin). The source of the bacteremia was never identified. She was on no medications before her current admission.On this presentation, her vital signs included blood pressure of 115/54 mmHg, heart rate of 114 beats/min and O 2 saturation on room air of 99%. Her initial physical examination revealed expressive aphasia, right facial droop and right arm weakness. Her lungs were clear to auscultation. On a precordial examination, her first and second heart sounds were normal, and there was a systolic murmur heard at the left lower sternal border. She had no signs of peripheral edema.Her initial bloodwork showed a white blood cell count of 6.4×10 9 /L (normal value 4×10 9 /L to 11×10 9 /L), hemoglobin 92 g/L (normal value 120 g/L to 160 g/L), mean corpuscular volume 87 L (normal value 80 L to 100 L), platelets 258×10 9 /L (normal value 140×10 9 /L to 450×10 9 /L), international normalized ratio 1.2, partial thromboplastin time 29 s (normal value 24 s to 35 s), urea 11.4 mmol/L (normal value 2.5 mmol/L to 8.0 mmol/L), creatinine 85 μmol/L (normal value 40 μmol/L to 115 μmol/L), magnesium 0.82 mmol/L (normal value 0.7 mmol/L to 1.0 mmol/L) and troponin I 0.61 μg/L (normal value less than 0.15 μg/L).An electrocardiogram showed sinus tachycardia with nonspecific T wave changes in the lateral leads ( Figure 1).Computed tomography of the head confirmed a left middle cerebral artery territory stroke involving primarily the left insular cortex and a portion of the left frontal lobe.The patient was admitted to neurology. She was started on acetylsalicylic acid 325 mg daily, and was given intravenous fluids for dehydration.Within 12 h of presentation, she suddenly developed clinical and radiographic pulmonary edema. She was found to have a loud decrescendo diastolic murmur best heard at the left lower sternal border. Her troponin I level increased to a peak of 0.71 μg/L. Her clinical findings were highly suspicious for aortic valve endocarditis with severe aortic insufficiency and associated congestive heart failure. Due to her clinical deterioration, she was transferred to a cardiology service.Subsequent investigations included a helical computed tomography scan of the lungs, which revealed a filling defect in an anterior segmental branch of the pulmonary artery in the left upper lobe, suspected to be a pulmonary embolus. In addition, a round globular filling defect measuring 1.3 cm × 1.0 cm, which was suspicious for a clot, was identified in the left atrial appendage (LAA). No deep venous thromboses in the legs were seen. The patient wa...

In response to “Left atrial thrombus in a case of severe aortic stenosis with severe left ventricular dysfunction: An incidental finding on transesophageal echocardiography”

“…[ 3 ] Left atrial (LA) thrombus is generally seen in the presence of atrial fibrillation (AF) and severe mitral stenosis with or without AF. [ 4 ] In both the clinical situations, the flow of blood from LA to LV is slow and flow velocity in LAA is low. The presence of LA thrombus in patients with sinus rhythm (SR) is rare.…”