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A free-floating left atrial mass
Clinical Picture
A free-floating left atrial mass Marco Pocar, Alda Bregasi, Davide Passolunghi, Francesco Donatelli Lancet 2012; 379: 152 Published Online November 4, 2011 DOI:10.1016/S01406736(11)60818-0 Department of Cardiovascular Sciences, Università degli Studi di Milano, Scientific Institute MultiMedica Hospital, Milan, Italy (M Pocar MD, A Bregasi MD, D Passolunghi MD, F Donatelli MD) Correspondence to: Dr Marco Pocar, Department of Cardiovascular Sciences, Università degli Studi di Milano, Scientific Institute MultiMedica Hospital, Via Milanese, 300, I-20099 Sesto San Giovanni, Milan, Italy [email protected]
A 78-year-old woman was transferred to our stroke unit 10 days after cerebral infarction. Her left hemisphere was affected, resulting in residual aphasia and mild right hemiparesis. Medical history included coronary artery bypass grafting 18 years before, and atrial fibrillation. Longstanding warfarin therapy had been temporarily suspended, and subcutaneous nadroparin initiated in advance of recent orthopaedic surgery. Twodimensional and three-dimensional transoesophageal echocardiography (figure A, B; see also webvideo 1) showed a 6 cm diameter free-floating left atrial mass, A Thrombus
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suggesting embolisation was the cause of the stroke. The mass had no mural attachment and could not cross the mitral valve orifice (figure C; see also webvideo 2). Nadroparin was immediately switched to an intravenous unfractioned heparin infusion. Cardiac surgery was deferred until 15 days after stroke onset, during which time the heparin infusion was continued and intracranial haemorrhage was excluded by CT. At surgery, the mass was successfully removed and was consistent with a left atrial ball thrombus.
B Left atrium
Thrombus Atrial free wall
Left ventricle
C Thrombus in mitral valve orifice
Left atrium
Left ventricle Atrial septum
Figure: Free-floating giant left atrial thrombus (A) and (B) show the complete absence of atrial wall attachments in two-dimensional and three-dimensional transoesophageal echocardiograms; (C) shows the thrombus unable to cross the mitral valve orifice in view of its size (scale in cm).
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www.thelancet.com Vol 379 January 14, 2012
A free-floating left atrial mass Marco Pocar, Alda Bregasi, Davide Passolunghi, Francesco Donatelli Lancet 2012; 379: 152 Published Online November 4, 2011 DOI:10.1016/S01406736(11)60818-0 Department of Cardiovascular Sciences, Università degli Studi di Milano, Scientific Institute MultiMedica Hospital, Milan, Italy (M Pocar MD, A Bregasi MD, D Passolunghi MD, F Donatelli MD) Correspondence to: Dr Marco Pocar, Department of Cardiovascular Sciences, Università degli Studi di Milano, Scientific Institute MultiMedica Hospital, Via Milanese, 300, I-20099 Sesto San Giovanni, Milan, Italy [email protected]
A 78-year-old woman was transferred to our stroke unit 10 days after cerebral infarction. Her left hemisphere was affected, resulting in residual aphasia and mild right hemiparesis. Medical history included coronary artery bypass grafting 18 years before, and atrial fibrillation. Longstanding warfarin therapy had been temporarily suspended, and subcutaneous nadroparin initiated in advance of recent orthopaedic surgery. Twodimensional and three-dimensional transoesophageal echocardiography (figure A, B; see also webvideo 1) showed a 6 cm diameter free-floating left atrial mass, A Thrombus
See Online for webvideos
suggesting embolisation was the cause of the stroke. The mass had no mural attachment and could not cross the mitral valve orifice (figure C; see also webvideo 2). Nadroparin was immediately switched to an intravenous unfractioned heparin infusion. Cardiac surgery was deferred until 15 days after stroke onset, during which time the heparin infusion was continued and intracranial haemorrhage was excluded by CT. At surgery, the mass was successfully removed and was consistent with a left atrial ball thrombus.
B Left atrium
Thrombus Atrial free wall
Left ventricle
C Thrombus in mitral valve orifice
Left atrium
Left ventricle Atrial septum
Figure: Free-floating giant left atrial thrombus (A) and (B) show the complete absence of atrial wall attachments in two-dimensional and three-dimensional transoesophageal echocardiograms; (C) shows the thrombus unable to cross the mitral valve orifice in view of its size (scale in cm).
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www.thelancet.com Vol 379 January 14, 2012