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

Abstract

DESCRIPTIONA 77-year-old man with a history of atrial fibrillation presented with bilateral loss of vision. A CT scan revealed acute cerebral infarction in the left occipital lobe. Cardiogenic embolic stroke was diagnosed. Treatment with intravenous heparin and antioxidative radical scavenger, edaravone and oral warfarin was started. Nevertheless, he developed new aphasia, right-sided paralysis and left conjugate deviation of the eyes 3 weeks later. MRI revealed a new cerebral infarction in his temporal lobe. He was admitted to our hospital for further investigation and treatment. The ejection fraction of the left ventricle was measured as 79% by transthoracic echocardiography and there was moderate mitral regurgitation. Transoesophageal echocardiography revealed the presence of a 28×38 mm round mass, possibly a thrombus in the left atrium, suggesting that embolisation was the cause of the stroke ( figure 1A,B, arrows). The round mass was free floating in the mitral regurgitation flow, mimicking a whale spray above the mitral valve orifice without mural attachment (figure 1B, arrows, arrowhead and video 1). The patient received aggressive anticoagulation therapy, but did not undergo a surgical operation to remove the mobile mass because of a decreased level of consciousness. He died after returning to the referral hospital. A left atrial mass may result in sudden circulatory collapse. 1Transoesophageal 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.

Left Atrial Thrombus Present: Is That about It?

“…Two-dimensional (2D) echocardiography is extremely helpful in determining the nature, size, spatial orientation of masses that most commonly include left atrial thrombus, prolapsing type of left atrial myxoma, papillary fibroelastomas, Lambl's excrescences, and fragments of vegetations. 8 Stasis of blood as seen in patients with mitral stenosis and the presence of atrial fibrillation or a poorly contracting LA predispose to the formation of thrombi in the LA, more commonly its appendage. Thrombus can be readily identified by TTE with a high specificity.…”