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Calcified mural thrombus in the left auricle
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CALCIFIED M U R A L T H R O M B U S IN T H E LEFT A U R I C L E BY H. P. K E N T , M.A., M.B., D.M.R.D. RADIOLOGIST~ HACKNEY HOSPITAL, LONDON, FORMERLY SENIOR REGISTRAR~ LONDON HOSPITAL
AND N. D. MORR1SON, M.R.C.S., L.R.C.P., D.M.R.D. SENIOR REGISTRAR, RADIODIAGNOSTIC DEPARTMENT, LONDON HOSPITAL
W ~ - h a v e t h o u g h t it w o r t h w h i l e to r e p o r t a case in w h i c h calcification of a t h r o m b u s in t h e left auricle was s e e n in r a d i o g r a p h s a n d c o n f i r m e d at autopsy, b e c a u s e t h e r e a r e few s u c h r e p o r t s a n d since t h e diagnosis o f calcification i n t h r o m b i f r o m calcification in t h e e n d o c a r d i u m o f - t h e left auricle is a difficult one. S c h o l z i n i 9 2 4 first d e s c r i b e d t h e r e c o g n i t i o n of m u r a l t h r o m b i b y X - r a y m e t h o d s i n t w o cases of mitral stenosis with embolic phenomena. I n b o t h of t h e s e cases a film o f t h e c h e s t s h o w e d a n oval, d e n s e c i r c u m s c r i b e d s h a d o w i n t h e basal p a r t of t h e h e a r t localized to t h e left auricle. I t is a m a t t e r of i n t e r e s t t h a t t h e d i a g n o s i s in t h e first p a t i e n t was s u g g e s t e d b y a clinician, D r . Isaac Adler, w h o c o r r e l a t e d t h e e m b o l i c p h e n o m e n a w i t h t h e oval d e n s e s h a d o w i n t h e left auricle. I n b o t h p a t i e n t s e v e n t u a l n e c r o p s y c o n f i r m e d t h e p r e s e n c e of a large t h r o m b u s w h i c h was h a r d a n d b r i t t l e , b u t n o t calcified. I n I933 Besser a n d S c h i l l i n g d e s c r i b e d 2 cases of calcified m u r a l t h r o m b u s . I n t h e first p a t i e n t , w h o suffered f r o m syphilis, a calcified s h a d o w was s e e n to lie o n t h e r i g h t side of t h e h e a r t a n d at p o s t - m o r t e m was f o u n d to b e a t h r o m b u s in t h e r i g h t auricle. T h e i r s e c o n d p a t i e n t h a d a calcified t h r o m b u s of u n k n o w n aetiology in t h e left a u r i c u l a r a p p e n d a g e . T h e r e was n o n e c r o p s y , b u t t h e films of this case as also of t h e i r first are of good q u a l i t y a n d c o n v i n c i n g . H e e r e n i n 1934 s h o w e d b e a u t i f u l films of a p a t i e n t w i t h m i t r a l stenosis w h o h a d a calcified t h r o m b u s in t h e left a u r i c u l a r a p p e n d a g e , b u t h e r e again t h e r e was n o n e c r o p s y . A r e n d t ( i 9 3 o ) a n d Ftissl ( i 9 3 6 ) each d e s c r i b e d a case of a n u n c a l c i f i e d t h r o m b u s i n p a t i e n t s d y i n g o f c o n g e s t i v e h e a r t failure f r o m m i t r a l stenosis. A l t h o u g h in b o t h cases f l u o r o s c o p y s h o w e d d i m i n i s h e d p u l s a t i o n i n t h e r e g i o n i n v o l v e d b y t h e t h r o m b u s t h e d i a g n o s i s was n o t m a d e radiologically. B e r k in i 9 3 9 p r e s e n t e d a p a t i e n t w i t h m i t r a l stenosis in w h o m a calcified t h r o m b u s in t h e left a u r i c u l a r a p p e n d a g e was f o u n d o n s c r e e n i n g . T h i s was c o n f i r m e d at n e c r o p s y . I n a m o r e r e c e n t p a p e r E v a n s a n d B e n s o n ( i 9 4 8 ) state t h a t a t h r o m b u s c a n n o t b e d e t e c t e d radiologically u n l e s s calcified.
Case R e c o r d . - - M r s . R. F., aged 58, was admitted for the first time to the London Hospital on Nov. 4, 1948. There was no previous history of rheumatic fever or chorea, but for the last fifteen years she had suffered from paroxysmal nocturnal dyspncea occurring about once a fortnight. Dyspneea on exertion, swelling of the ankles and abdomen, anorexia, and vomiting began four months before admission gradually getting worse. For the last few days there had been some jaundice. There had never been any embolic phenomena. Clinical Findings.--On examination she was very ill, breathless and cyanosed, as well as jaundiced and wasted. There was gross cedema of the lower extremities extending up to the lumbar region. T h e findings in the cardiovascular system showed that she had auricular fibrillation with a pulse deficit of 89, the radial pulse being 64. T h e apex-beat was 4 in. from the midtine in the 5th interspace. There was a constant thrill at the apex, and a loud blowing systolic as well as a harsh diastolic m u r m u r were heard in this region. No physical signs to suggest an aortic incompetence were found. T h e blood-pressure was iao/8o. T h e neck veins were distended. At the bases of the lungs there were crepltations. In the abdomen there was considerable ascites and enlargement of the liver. T h e urine contained a cloud of albumfn, but no bile. Blood-culture was sterile. T h e serum bilirubin was 4-i rag. per cent. P r o g r e s s . - - T h e clinical diagnosis was mitral stenosis with auricular fibrillation and heart failure. T h e patient was given digitalis with at first an excellent response. Mersalyl was also given and abdominal paracentesis was performed. She gradually improved, but in January, i949, she developed a right-sided pleural effusion. Since she was anxious to go home she was discharged on Jan. 21, I949, only to be re-admitted moribund on Feb. 8. R a d i o l o g y . - - T h e films were obtained in January, 1949, after the onset of the pleural effusion. T h e ordinary postero-an~cerior film of the chest (Fig. Io5) showed a heart moderately enlarged or displaced to the
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left, a very p r o m i n e n t p u l m o n a r y artery, a n d a small aortic knuckle. T h e r i g h t b o r d e r of t h e heart could not be defined since there was a right pleural effusion reaching u p into t h e right m i d - z o n e . T h e hilar s h a d o w s were p r o m i n e n t a n d there were m o d e r a t e congestive c h a n g e s in t h e l u n g fields. T h e trachea was central. T h e lateral view (Fig. lO6) s h o w e d a m u c h r e d u c e d retrocardiac space consistent w i t h considerable enlargem e n t of t h e left auricle. It was noticed that t h e r e was a crescentic calcified s h a d o w in the region of t h e left auricle, concave forwards a n d c o r r e s p o n d i n g to t h e posterior part of t h e left auricle. T h e posterior edge of this calcification was well defined. I n addition there were several small streaks of calcification f a n n i n g o u t in an anterior direction f r o m t h e posterior r i m of calcification. T h e over-penetrated postero-anterior view (Fig. lO7) revealed t h a t t h e calcified s h a d o w was oval, I1"5 by 7 cm. in diameter, with its longitudinal axis in t h e horizontal plane. It was lying practically symmetrically in t h e midline over t h e dorsal spine at t h e level of D. '8-IO a n d projecting equally to b o t h sides. O n t h e left
Fig. ios.--Enlargement of the heart with mitral configuration. Slight vascular congestion ; right pleural effusion. Calcified thrombus not visible.
Fig. lO6.--Calcified thrombus occupying posterior part of enlarged left auricle.
side t h e calcified r i m did n o t reach t h e left border of t h e heart by a good m a r g i n . O n t h e right side the relation of this s h a d o w to t h e right border of t h e heart could n o t be defined as t h e right h e a r t s h a d o w was o b s c u r e d b y t h e pleural effusion. T h e left m a i n b r o n c h u s was n o t elevated a n d t h e r e was no obvious w i d e n i n g of t h e angle of divergence of t h e m a i n bronchi. N o convincing evidence of calcification of t h e mitral valve was seen, a l t h o u g h t h e r e was one small p a t c h of calcification at t h e left cardiophrenic angle considered to be due m o s t probably to calcified costal cartilage, since there was o t h e r evidence of costal cartilage calcification. T h e findings were t h u s consistent with mitral stenosis with congestive heart failure. T h e large calcified s h a d o w was erroneously i n t e r p r e t e d by u s as d u e to calcification in t h e e n d o c a r d i u m of the left auricle. T h e r e was no d o u b t about t h e e n l a r g e m e n t of t h e left auricle s h o w n by its projection across to the right of t h e dorsal spine, as so often seen in cases of mitral stenosis. T h e patient was too ill for a b a r i u m swallow or for f u r t h e r films. P a t h o l o g y . - - N e c r o p s y was p e r f o r m e d in t h e L o n d o n Hospital ( P . M . 54/1949) by Dr. W . W. W o o d s , a n d an abstract of t h e p o s t - m o r t e m findings follows. T h e pathological diagnosis was h e a r t failure, mitral stenosis, c h r o n i c r h e u m a t i c endocarditis. Small pericardial effusion (4 oz.). Severe mitral s t e n o s i s - - t h e slit b e i n g I cm. long. T h i c k e n i n g a n d contraction of t h e mitral c u s p s c o n t a i n i n g one p a t c h of calcification of 0'6 cm. diameter. T h i c k e n i n g a n d s h o r t e n i n g of t h e chord~e tendine~e, s o m e of t h e m fused. Aortic valve n o r m a l except for fibrous fusion of adjacent 0'4 cm. of anterior a n d left posterior cusps. T r i c u s p i d valve normal.
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Curved plaque (up to 3"5 cm. thick) of old, very friable laminated brown thrombus adherent all over the posterior and upper walls of the left auricle, covered with a thin layer of more recent thrombus. Plate (0. 4 cm. thick) of calcification in the clot near its attachment to the endocardium. Dilatation of left auricle (9 cm. in diameter). Hypertrophy and slight dilatation of right ventricle. " Dilatation (8 cm. in diameter) and slight hypertrophy of right auricle. No dilatation or hypertrophy of left ventricle, possibly slight atrophy. Moderate aortic atheroma. Clear pleural effusions (32 oz. right, 5 oz. left). Collapse of about lower half of right lower lobe and lower border of middle lobe. Brown pigmentation without induration or oedema or recent congestion of lungs. The remainder of the findings were consistent with heart failure. Microscopical sections were made of two pieces of left auricle, each 3 cm. long, at the sire'of the calcification. There is an inner layer of fibrin thrombus. The outer part of this is in process of organization by an open mesh of collagen containing scanty fibroblasts, capillaries, and pigment macrophages. In continuity with the outer part of this is a layer where the thrombus has been organized into dense hyaline fibrous tissue containing very few fibrocytes. This layer varies from 0.2 to 0'5 cm. in thickness. It is attached to, but in preparation of the sections has in places become easily separate from, the endocardium, which is not appreciably altered in structure, having its normal pattern of interwoven muscle and elastic fibres. The musculature of the auricle is normal. The plates of calcification lie in the hyaline fibrous organized part of the thrombus; they are everywhere separated from the endocardium by at least a narrow, in places quite broad, zone of uncalcified tissue. D i s c u s s i o n . - - T h r o m b i m a y be f o u n d in any c h a m b e r of the heart, but there is a predilection to their f o r m a t i o n in the auricles and their a p p e n d ages. I n a series of 56 such cases collected by Scholz ( i 9 2 4 - 5 ) f r o m the literature and verified at p o s t - m o r t e m no less t h a n 53 had t h r o m b i in one of the auricles, mostly in t h e left auricle. I n 7 patients in this series t h r o m b i w e r e also f o u n d in one of the ventricles. A c c o r d i n g to Aschoff the m o s t i m p o r t a n t factor in the f o r m a t i o n of a t h r o m b u s in mitral Fig. io7.--Over-penetrated post. . . . anterior v i e w . stenosis is the dilatation of t h e left auricle resultOval calcified thrombus lying in the basal part of heart in region ofleft auricle, ing in a slowing of the b l o o d - s t r e a m . Evans and Benson state that mitral stenosis is essential for the f o r m a t i o n of a ball t h r o m b u s in the left auricle and that auricular fibrillation is a c o n t r i b u t i n g factor, t h r o m b i rarely f o r m i n g w i t h a n o r m a l cardiac r h y t h m . A t h r o m b u s m a y be lying free in the left auricle, or it m a y be attached either by a pedicle or by a broad base, as in our case. T h e size varies considerably f r o m small to v e r y large ; it m a y fill practically the whole of the auricle. T h r o m b i t e n d to be r o u n d or oval, and are usually uncalcified. Calcification occasionally occurs, 3 of the t h r o m b i in the series q u o t e d by Scholz being partially calcified as d e m o n s t r a t e d at necropsy. T h e radiological appearance of a t h r o m b u s in the left auricle varies w i t h its location, size, and degree of calcification. As previously stated, Evans and Benson considered that a t h r o m b u s c a n n o t be d e t e c t e d unless calcified. T h i s is also Roesler's opinion. T h i s is u n d o u b t e d l y t r u e in the m a j o r i t y of cases, certainly w i t h small uncalcified t h r o m b i . Scholz in his original paper, however, correctly suggested the diagnosis in b o t h his patients, w h e r e the t h r o m b i were of considerable size. H e stated " r o u n d or oval c i r c u m s c r i b e d shadows within the basal part of the heart, particularly if associated w i t h enlargem e n t and lack of pulsation in the region of the left auricle in a case of mitral stenosis are practically
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pathognomonic of a thrombus in the left auricle " V~refeel that the shadow of an enlarged left auricle in mitra] stenosis as seen in an overpenetrated film of the chest could very easilybe misinterpreted as a large thrombus. In such circumstances one might be guided by the presence or absence of embolic phenomena--but undoubtedly very considerable reserve is indicated in diagnosing an uncalcified thrombus. The diagnostic problem with calcified thrombi is different since it raises the differential diagnosis of calcified intracardiac shadows in general. Smallcalcified thrombi in the left auricular appendage tend to be rounded or semicircular with the convexity outwards. Their position and appearance, especially if associated with some lack of local pulsation appear to be fairly typical. Heeren's, Berk's, and Besser and Schilling's second case are typical examples of this type of thrombus. The interpretation of a large calcified mural thrombus filling most of the left auricle is more difficult. The case presented in this paper is a good example. We misinterpreted the findings as those of endocardial calcification in the left auricle. Only 5 cases of extensive auricular endocardial calcification diagnosed radiologically are on record. The first was diagnosed by Bedford and quoted by Kerley in 1938. In 1945 Begg demonstrated a further case and quite recently Epstein reported 3 more. These 5 patients had striking similarities--they all occurred in patients suffering from mitral stenosis in whom the ]eft auricle was enlarged to a varying extent. All showed fairly extensive calcification in the wall of the left auricle, predominantly posteriorly. Fluoroscopyin Begg's patient showed absence of left auricular contraction ; no mention of screening appearances was made by Kerley. Epstein showed auricular contractions to be present in his patients and confirmed this kymographically. In none of these cases was there pathological confirmation. It is interesting to note that a similar case reported by Fernandez and Ruiz in 1944 at post-mortem showed a calcified, stony hard, and rigid left auricle, obviously incapable of contraction, although this was not checked by fluoroscopy, nor seen on their routine film of the chest. On reviewing these reports on auricular calcification in mitral stenosis one is struck with the great similarities in appearance in Epstein's first case with those in the case presented in this paper. In both the main features of the calcification in the left auricle are the oval shape and the sharp definition of its edge seen in the postero-anterior view. One cannot dismiss the possibility that Epstein's case was not in fact one of a calcified mural thrombus. Indeed, Ker]ey's reproduction, an oblique view, could also be a calcified thrombus. Certain other causes of calcification within the cardiac contour have to be excluded in the diagnosis of calcified auricular thrombi. Pericardial calcification if extensive should be easy to rule out, but if this type of calcification is localized to the left postero-lateral part of the heart, as in Berk's case, it may cause considerable diagnostic difficulties. Myocardialcalcification is more usually localized tO the ventricles. Calcified valves can be differentiated by their position and dancing motion on screening. This also applies to calcification in a mitral annulus fibrosus. A calcified coronary artery on the left side may bear a similarity to a thrombus in the auricular appendage in the postero-anterior view, but on screening the linear shadowing in the calcified vessel should be apparent, and the type of patient and history will help. A calcified cardiac aneurysm will be localized to the ventricle, and the history and shape of the heart should be helpful. A demonstrable calcified cardiac ecchinococcus cyst must be exceptional. This also applies to calcification in a cardiac tumour. Lastly extracardiac calcified shadows can be ruled out by careful fluoroscopy. From the technical point of view the value of an overpenetrated postero-anterior film of the chest in cases of mitral stenosis cannot be sufficiently stressed. This gives an accurate impression of the dimensions of the enlarged ]eft auricle, and demonstrates any pressure effects on the bronchial tree, such as widening of the angle of divergence of the main bronchi, due to elevation of the left main bronchus by the auricle. In addition it will show up areas of calcification within the cardiac contour unsuspected on the routine posterior-anterior view. This is borne out by our case where the
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calcified thrombus was quite invisible on the ordinary posterior-anterior view. Lateral and oblique films, as well as screening and barium swallow studies will help to localize the area of calcification. Nevertheless it would appear doubtful if this routine, including careful fluoroscopy, could help to differentiate a large calcified mural thrombus, as present in our case, from an extensive area of endoeardial calcification in the left auricle. On screening in both conditions one would expect to find some diminution or even absence of contraction of the left auricle. We have no personal experience of kymography. To our knowledge this method has been employed only once in a case of calcified thrombus (Heeren) and the pulsations were considered normal. But this was a small thrombus in the auricular appendage. T h e assessment of the value of kymography in such cases will depend on future reports. T h e length of exposure required during tomography makes it extremely doubtful if this method of investigation would give sufficient information of diagnostic importance as regards the differentiation of the two conditions under discussion, unless the thrombus is very heavily calcified in depth. T h u s the assessment of the significance of a large calcified shadow within the contours of the left auricle must depend upon the correlation of the clinica! findings with the radiological features. In the presence of a history of embolic phenomena a diagnosis of a thrombus might be submitted. Summary.--1. A case of an extensively calcified mural thrombus in the left auricle in a patient suffering from mitral stenosis and confirmed by necropsy is presented. 2. T h e literature on the radiologieal demonstration of calcified t h r o m b i in the left auricle and on left atrial calcification is reviewed. 3. T h e differential diagnosis of a calcified mural thrombus from other cardiac calcifications is briefly discussed. 4. T h e value of an over-penetrated film of the chest in cases of mitral stenosis is stressed. 5. It is suggested that it is difficult if not impossible to differentiate a large calcified mural thrombus in the left auricle from extensive endocardial calcification in the left auricle. Our grateful thanks are due to Dr. R. R. Bomford for permission to publish this case, to Dr. W. W. Woods for his pathological reports and to Dr. M . H. Jupe for his constant encouragement. REFERENCES ARENDT, J. (i93o), R6ntgenpraxis, z, 828. ASeHOPF, L. (I936), Pathologische Anatomie. Jena : Fischer. BEDFORD, EVAN, quoted by P. KERLEY (I938), A Textbook of X-ray Diagnosis. London: H. K. Lewis. BEet, A. C. (i945), N.Z. reed. J., 44, 315. BERK, L. H. (I939), Arch. intern. Med., 63, II83. BESSER, F., and SCHILLING, C. (I933), Dtseh. Arch. hlin. Med., I75 , 50. EPSTEIN, B. S. (i949) Amer. J. Roentgenol., 6I, 202. EVANS, W., and BENSON, R. (I948), Brit. Heart J., IO, 39. FERNANDEZ, F., and RvIz, A. T. (I944), Med. Madrid, I2, 367. F~SSL, E. (I936), Rdntgenpraxis, 8, 377HEEREN, J, (I934) , Fortschr. R6ntgenstr., 5o, 49o. ROESLER, H. (I937), Clinical Roentgenology of the Cardiovascular System. Springfield, Ill. : C. C. Thomas. SCHOLZ, T. H. (I9z4), Fortschr. R6ntgenstr., 32, 416. - - - - (I924-5) , Z. klin. Med., IOI, 343.
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CALCIFIED M U R A L T H R O M B U S IN T H E LEFT A U R I C L E BY H. P. K E N T , M.A., M.B., D.M.R.D. RADIOLOGIST~ HACKNEY HOSPITAL, LONDON, FORMERLY SENIOR REGISTRAR~ LONDON HOSPITAL
AND N. D. MORR1SON, M.R.C.S., L.R.C.P., D.M.R.D. SENIOR REGISTRAR, RADIODIAGNOSTIC DEPARTMENT, LONDON HOSPITAL
W ~ - h a v e t h o u g h t it w o r t h w h i l e to r e p o r t a case in w h i c h calcification of a t h r o m b u s in t h e left auricle was s e e n in r a d i o g r a p h s a n d c o n f i r m e d at autopsy, b e c a u s e t h e r e a r e few s u c h r e p o r t s a n d since t h e diagnosis o f calcification i n t h r o m b i f r o m calcification in t h e e n d o c a r d i u m o f - t h e left auricle is a difficult one. S c h o l z i n i 9 2 4 first d e s c r i b e d t h e r e c o g n i t i o n of m u r a l t h r o m b i b y X - r a y m e t h o d s i n t w o cases of mitral stenosis with embolic phenomena. I n b o t h of t h e s e cases a film o f t h e c h e s t s h o w e d a n oval, d e n s e c i r c u m s c r i b e d s h a d o w i n t h e basal p a r t of t h e h e a r t localized to t h e left auricle. I t is a m a t t e r of i n t e r e s t t h a t t h e d i a g n o s i s in t h e first p a t i e n t was s u g g e s t e d b y a clinician, D r . Isaac Adler, w h o c o r r e l a t e d t h e e m b o l i c p h e n o m e n a w i t h t h e oval d e n s e s h a d o w i n t h e left auricle. I n b o t h p a t i e n t s e v e n t u a l n e c r o p s y c o n f i r m e d t h e p r e s e n c e of a large t h r o m b u s w h i c h was h a r d a n d b r i t t l e , b u t n o t calcified. I n I933 Besser a n d S c h i l l i n g d e s c r i b e d 2 cases of calcified m u r a l t h r o m b u s . I n t h e first p a t i e n t , w h o suffered f r o m syphilis, a calcified s h a d o w was s e e n to lie o n t h e r i g h t side of t h e h e a r t a n d at p o s t - m o r t e m was f o u n d to b e a t h r o m b u s in t h e r i g h t auricle. T h e i r s e c o n d p a t i e n t h a d a calcified t h r o m b u s of u n k n o w n aetiology in t h e left a u r i c u l a r a p p e n d a g e . T h e r e was n o n e c r o p s y , b u t t h e films of this case as also of t h e i r first are of good q u a l i t y a n d c o n v i n c i n g . H e e r e n i n 1934 s h o w e d b e a u t i f u l films of a p a t i e n t w i t h m i t r a l stenosis w h o h a d a calcified t h r o m b u s in t h e left a u r i c u l a r a p p e n d a g e , b u t h e r e again t h e r e was n o n e c r o p s y . A r e n d t ( i 9 3 o ) a n d Ftissl ( i 9 3 6 ) each d e s c r i b e d a case of a n u n c a l c i f i e d t h r o m b u s i n p a t i e n t s d y i n g o f c o n g e s t i v e h e a r t failure f r o m m i t r a l stenosis. A l t h o u g h in b o t h cases f l u o r o s c o p y s h o w e d d i m i n i s h e d p u l s a t i o n i n t h e r e g i o n i n v o l v e d b y t h e t h r o m b u s t h e d i a g n o s i s was n o t m a d e radiologically. B e r k in i 9 3 9 p r e s e n t e d a p a t i e n t w i t h m i t r a l stenosis in w h o m a calcified t h r o m b u s in t h e left a u r i c u l a r a p p e n d a g e was f o u n d o n s c r e e n i n g . T h i s was c o n f i r m e d at n e c r o p s y . I n a m o r e r e c e n t p a p e r E v a n s a n d B e n s o n ( i 9 4 8 ) state t h a t a t h r o m b u s c a n n o t b e d e t e c t e d radiologically u n l e s s calcified.
Case R e c o r d . - - M r s . R. F., aged 58, was admitted for the first time to the London Hospital on Nov. 4, 1948. There was no previous history of rheumatic fever or chorea, but for the last fifteen years she had suffered from paroxysmal nocturnal dyspncea occurring about once a fortnight. Dyspneea on exertion, swelling of the ankles and abdomen, anorexia, and vomiting began four months before admission gradually getting worse. For the last few days there had been some jaundice. There had never been any embolic phenomena. Clinical Findings.--On examination she was very ill, breathless and cyanosed, as well as jaundiced and wasted. There was gross cedema of the lower extremities extending up to the lumbar region. T h e findings in the cardiovascular system showed that she had auricular fibrillation with a pulse deficit of 89, the radial pulse being 64. T h e apex-beat was 4 in. from the midtine in the 5th interspace. There was a constant thrill at the apex, and a loud blowing systolic as well as a harsh diastolic m u r m u r were heard in this region. No physical signs to suggest an aortic incompetence were found. T h e blood-pressure was iao/8o. T h e neck veins were distended. At the bases of the lungs there were crepltations. In the abdomen there was considerable ascites and enlargement of the liver. T h e urine contained a cloud of albumfn, but no bile. Blood-culture was sterile. T h e serum bilirubin was 4-i rag. per cent. P r o g r e s s . - - T h e clinical diagnosis was mitral stenosis with auricular fibrillation and heart failure. T h e patient was given digitalis with at first an excellent response. Mersalyl was also given and abdominal paracentesis was performed. She gradually improved, but in January, i949, she developed a right-sided pleural effusion. Since she was anxious to go home she was discharged on Jan. 21, I949, only to be re-admitted moribund on Feb. 8. R a d i o l o g y . - - T h e films were obtained in January, 1949, after the onset of the pleural effusion. T h e ordinary postero-an~cerior film of the chest (Fig. Io5) showed a heart moderately enlarged or displaced to the
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left, a very p r o m i n e n t p u l m o n a r y artery, a n d a small aortic knuckle. T h e r i g h t b o r d e r of t h e heart could not be defined since there was a right pleural effusion reaching u p into t h e right m i d - z o n e . T h e hilar s h a d o w s were p r o m i n e n t a n d there were m o d e r a t e congestive c h a n g e s in t h e l u n g fields. T h e trachea was central. T h e lateral view (Fig. lO6) s h o w e d a m u c h r e d u c e d retrocardiac space consistent w i t h considerable enlargem e n t of t h e left auricle. It was noticed that t h e r e was a crescentic calcified s h a d o w in the region of t h e left auricle, concave forwards a n d c o r r e s p o n d i n g to t h e posterior part of t h e left auricle. T h e posterior edge of this calcification was well defined. I n addition there were several small streaks of calcification f a n n i n g o u t in an anterior direction f r o m t h e posterior r i m of calcification. T h e over-penetrated postero-anterior view (Fig. lO7) revealed t h a t t h e calcified s h a d o w was oval, I1"5 by 7 cm. in diameter, with its longitudinal axis in t h e horizontal plane. It was lying practically symmetrically in t h e midline over t h e dorsal spine at t h e level of D. '8-IO a n d projecting equally to b o t h sides. O n t h e left
Fig. ios.--Enlargement of the heart with mitral configuration. Slight vascular congestion ; right pleural effusion. Calcified thrombus not visible.
Fig. lO6.--Calcified thrombus occupying posterior part of enlarged left auricle.
side t h e calcified r i m did n o t reach t h e left border of t h e heart by a good m a r g i n . O n t h e right side the relation of this s h a d o w to t h e right border of t h e heart could n o t be defined as t h e right h e a r t s h a d o w was o b s c u r e d b y t h e pleural effusion. T h e left m a i n b r o n c h u s was n o t elevated a n d t h e r e was no obvious w i d e n i n g of t h e angle of divergence of t h e m a i n bronchi. N o convincing evidence of calcification of t h e mitral valve was seen, a l t h o u g h t h e r e was one small p a t c h of calcification at t h e left cardiophrenic angle considered to be due m o s t probably to calcified costal cartilage, since there was o t h e r evidence of costal cartilage calcification. T h e findings were t h u s consistent with mitral stenosis with congestive heart failure. T h e large calcified s h a d o w was erroneously i n t e r p r e t e d by u s as d u e to calcification in t h e e n d o c a r d i u m of the left auricle. T h e r e was no d o u b t about t h e e n l a r g e m e n t of t h e left auricle s h o w n by its projection across to the right of t h e dorsal spine, as so often seen in cases of mitral stenosis. T h e patient was too ill for a b a r i u m swallow or for f u r t h e r films. P a t h o l o g y . - - N e c r o p s y was p e r f o r m e d in t h e L o n d o n Hospital ( P . M . 54/1949) by Dr. W . W. W o o d s , a n d an abstract of t h e p o s t - m o r t e m findings follows. T h e pathological diagnosis was h e a r t failure, mitral stenosis, c h r o n i c r h e u m a t i c endocarditis. Small pericardial effusion (4 oz.). Severe mitral s t e n o s i s - - t h e slit b e i n g I cm. long. T h i c k e n i n g a n d contraction of t h e mitral c u s p s c o n t a i n i n g one p a t c h of calcification of 0'6 cm. diameter. T h i c k e n i n g a n d s h o r t e n i n g of t h e chord~e tendine~e, s o m e of t h e m fused. Aortic valve n o r m a l except for fibrous fusion of adjacent 0'4 cm. of anterior a n d left posterior cusps. T r i c u s p i d valve normal.
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Curved plaque (up to 3"5 cm. thick) of old, very friable laminated brown thrombus adherent all over the posterior and upper walls of the left auricle, covered with a thin layer of more recent thrombus. Plate (0. 4 cm. thick) of calcification in the clot near its attachment to the endocardium. Dilatation of left auricle (9 cm. in diameter). Hypertrophy and slight dilatation of right ventricle. " Dilatation (8 cm. in diameter) and slight hypertrophy of right auricle. No dilatation or hypertrophy of left ventricle, possibly slight atrophy. Moderate aortic atheroma. Clear pleural effusions (32 oz. right, 5 oz. left). Collapse of about lower half of right lower lobe and lower border of middle lobe. Brown pigmentation without induration or oedema or recent congestion of lungs. The remainder of the findings were consistent with heart failure. Microscopical sections were made of two pieces of left auricle, each 3 cm. long, at the sire'of the calcification. There is an inner layer of fibrin thrombus. The outer part of this is in process of organization by an open mesh of collagen containing scanty fibroblasts, capillaries, and pigment macrophages. In continuity with the outer part of this is a layer where the thrombus has been organized into dense hyaline fibrous tissue containing very few fibrocytes. This layer varies from 0.2 to 0'5 cm. in thickness. It is attached to, but in preparation of the sections has in places become easily separate from, the endocardium, which is not appreciably altered in structure, having its normal pattern of interwoven muscle and elastic fibres. The musculature of the auricle is normal. The plates of calcification lie in the hyaline fibrous organized part of the thrombus; they are everywhere separated from the endocardium by at least a narrow, in places quite broad, zone of uncalcified tissue. D i s c u s s i o n . - - T h r o m b i m a y be f o u n d in any c h a m b e r of the heart, but there is a predilection to their f o r m a t i o n in the auricles and their a p p e n d ages. I n a series of 56 such cases collected by Scholz ( i 9 2 4 - 5 ) f r o m the literature and verified at p o s t - m o r t e m no less t h a n 53 had t h r o m b i in one of the auricles, mostly in t h e left auricle. I n 7 patients in this series t h r o m b i w e r e also f o u n d in one of the ventricles. A c c o r d i n g to Aschoff the m o s t i m p o r t a n t factor in the f o r m a t i o n of a t h r o m b u s in mitral Fig. io7.--Over-penetrated post. . . . anterior v i e w . stenosis is the dilatation of t h e left auricle resultOval calcified thrombus lying in the basal part of heart in region ofleft auricle, ing in a slowing of the b l o o d - s t r e a m . Evans and Benson state that mitral stenosis is essential for the f o r m a t i o n of a ball t h r o m b u s in the left auricle and that auricular fibrillation is a c o n t r i b u t i n g factor, t h r o m b i rarely f o r m i n g w i t h a n o r m a l cardiac r h y t h m . A t h r o m b u s m a y be lying free in the left auricle, or it m a y be attached either by a pedicle or by a broad base, as in our case. T h e size varies considerably f r o m small to v e r y large ; it m a y fill practically the whole of the auricle. T h r o m b i t e n d to be r o u n d or oval, and are usually uncalcified. Calcification occasionally occurs, 3 of the t h r o m b i in the series q u o t e d by Scholz being partially calcified as d e m o n s t r a t e d at necropsy. T h e radiological appearance of a t h r o m b u s in the left auricle varies w i t h its location, size, and degree of calcification. As previously stated, Evans and Benson considered that a t h r o m b u s c a n n o t be d e t e c t e d unless calcified. T h i s is also Roesler's opinion. T h i s is u n d o u b t e d l y t r u e in the m a j o r i t y of cases, certainly w i t h small uncalcified t h r o m b i . Scholz in his original paper, however, correctly suggested the diagnosis in b o t h his patients, w h e r e the t h r o m b i were of considerable size. H e stated " r o u n d or oval c i r c u m s c r i b e d shadows within the basal part of the heart, particularly if associated w i t h enlargem e n t and lack of pulsation in the region of the left auricle in a case of mitral stenosis are practically
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pathognomonic of a thrombus in the left auricle " V~refeel that the shadow of an enlarged left auricle in mitra] stenosis as seen in an overpenetrated film of the chest could very easilybe misinterpreted as a large thrombus. In such circumstances one might be guided by the presence or absence of embolic phenomena--but undoubtedly very considerable reserve is indicated in diagnosing an uncalcified thrombus. The diagnostic problem with calcified thrombi is different since it raises the differential diagnosis of calcified intracardiac shadows in general. Smallcalcified thrombi in the left auricular appendage tend to be rounded or semicircular with the convexity outwards. Their position and appearance, especially if associated with some lack of local pulsation appear to be fairly typical. Heeren's, Berk's, and Besser and Schilling's second case are typical examples of this type of thrombus. The interpretation of a large calcified mural thrombus filling most of the left auricle is more difficult. The case presented in this paper is a good example. We misinterpreted the findings as those of endocardial calcification in the left auricle. Only 5 cases of extensive auricular endocardial calcification diagnosed radiologically are on record. The first was diagnosed by Bedford and quoted by Kerley in 1938. In 1945 Begg demonstrated a further case and quite recently Epstein reported 3 more. These 5 patients had striking similarities--they all occurred in patients suffering from mitral stenosis in whom the ]eft auricle was enlarged to a varying extent. All showed fairly extensive calcification in the wall of the left auricle, predominantly posteriorly. Fluoroscopyin Begg's patient showed absence of left auricular contraction ; no mention of screening appearances was made by Kerley. Epstein showed auricular contractions to be present in his patients and confirmed this kymographically. In none of these cases was there pathological confirmation. It is interesting to note that a similar case reported by Fernandez and Ruiz in 1944 at post-mortem showed a calcified, stony hard, and rigid left auricle, obviously incapable of contraction, although this was not checked by fluoroscopy, nor seen on their routine film of the chest. On reviewing these reports on auricular calcification in mitral stenosis one is struck with the great similarities in appearance in Epstein's first case with those in the case presented in this paper. In both the main features of the calcification in the left auricle are the oval shape and the sharp definition of its edge seen in the postero-anterior view. One cannot dismiss the possibility that Epstein's case was not in fact one of a calcified mural thrombus. Indeed, Ker]ey's reproduction, an oblique view, could also be a calcified thrombus. Certain other causes of calcification within the cardiac contour have to be excluded in the diagnosis of calcified auricular thrombi. Pericardial calcification if extensive should be easy to rule out, but if this type of calcification is localized to the left postero-lateral part of the heart, as in Berk's case, it may cause considerable diagnostic difficulties. Myocardialcalcification is more usually localized tO the ventricles. Calcified valves can be differentiated by their position and dancing motion on screening. This also applies to calcification in a mitral annulus fibrosus. A calcified coronary artery on the left side may bear a similarity to a thrombus in the auricular appendage in the postero-anterior view, but on screening the linear shadowing in the calcified vessel should be apparent, and the type of patient and history will help. A calcified cardiac aneurysm will be localized to the ventricle, and the history and shape of the heart should be helpful. A demonstrable calcified cardiac ecchinococcus cyst must be exceptional. This also applies to calcification in a cardiac tumour. Lastly extracardiac calcified shadows can be ruled out by careful fluoroscopy. From the technical point of view the value of an overpenetrated postero-anterior film of the chest in cases of mitral stenosis cannot be sufficiently stressed. This gives an accurate impression of the dimensions of the enlarged ]eft auricle, and demonstrates any pressure effects on the bronchial tree, such as widening of the angle of divergence of the main bronchi, due to elevation of the left main bronchus by the auricle. In addition it will show up areas of calcification within the cardiac contour unsuspected on the routine posterior-anterior view. This is borne out by our case where the
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calcified thrombus was quite invisible on the ordinary posterior-anterior view. Lateral and oblique films, as well as screening and barium swallow studies will help to localize the area of calcification. Nevertheless it would appear doubtful if this routine, including careful fluoroscopy, could help to differentiate a large calcified mural thrombus, as present in our case, from an extensive area of endoeardial calcification in the left auricle. On screening in both conditions one would expect to find some diminution or even absence of contraction of the left auricle. We have no personal experience of kymography. To our knowledge this method has been employed only once in a case of calcified thrombus (Heeren) and the pulsations were considered normal. But this was a small thrombus in the auricular appendage. T h e assessment of the value of kymography in such cases will depend on future reports. T h e length of exposure required during tomography makes it extremely doubtful if this method of investigation would give sufficient information of diagnostic importance as regards the differentiation of the two conditions under discussion, unless the thrombus is very heavily calcified in depth. T h u s the assessment of the significance of a large calcified shadow within the contours of the left auricle must depend upon the correlation of the clinica! findings with the radiological features. In the presence of a history of embolic phenomena a diagnosis of a thrombus might be submitted. Summary.--1. A case of an extensively calcified mural thrombus in the left auricle in a patient suffering from mitral stenosis and confirmed by necropsy is presented. 2. T h e literature on the radiologieal demonstration of calcified t h r o m b i in the left auricle and on left atrial calcification is reviewed. 3. T h e differential diagnosis of a calcified mural thrombus from other cardiac calcifications is briefly discussed. 4. T h e value of an over-penetrated film of the chest in cases of mitral stenosis is stressed. 5. It is suggested that it is difficult if not impossible to differentiate a large calcified mural thrombus in the left auricle from extensive endocardial calcification in the left auricle. Our grateful thanks are due to Dr. R. R. Bomford for permission to publish this case, to Dr. W. W. Woods for his pathological reports and to Dr. M . H. Jupe for his constant encouragement. REFERENCES ARENDT, J. (i93o), R6ntgenpraxis, z, 828. ASeHOPF, L. (I936), Pathologische Anatomie. Jena : Fischer. BEDFORD, EVAN, quoted by P. KERLEY (I938), A Textbook of X-ray Diagnosis. London: H. K. Lewis. BEet, A. C. (i945), N.Z. reed. J., 44, 315. BERK, L. H. (I939), Arch. intern. Med., 63, II83. BESSER, F., and SCHILLING, C. (I933), Dtseh. Arch. hlin. Med., I75 , 50. EPSTEIN, B. S. (i949) Amer. J. Roentgenol., 6I, 202. EVANS, W., and BENSON, R. (I948), Brit. Heart J., IO, 39. FERNANDEZ, F., and RvIz, A. T. (I944), Med. Madrid, I2, 367. F~SSL, E. (I936), Rdntgenpraxis, 8, 377HEEREN, J, (I934) , Fortschr. R6ntgenstr., 5o, 49o. ROESLER, H. (I937), Clinical Roentgenology of the Cardiovascular System. Springfield, Ill. : C. C. Thomas. SCHOLZ, T. H. (I9z4), Fortschr. R6ntgenstr., 32, 416. - - - - (I924-5) , Z. klin. Med., IOI, 343.