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Echocardiographic detection of free-floating left atrial thrombus
374
BRIEF REPORTS
FIGURE 1. A, leads VI to Vs recorded on a Fukuda electrocardiograph (model DU 3-S). showing a pulse-to-pulse interval (PPI) of 870 ms. B, leads I, II and III taken at the same time as in (A), but using a Marquette electrocardiograph machine (Series 3300) showing a PPI of 820 ms.
A
This was confirmed by taking ECGs on the 2 electrocardiograph machines during the same day (Fig. 1). Analysis of the pacemaker by a Medtronic Model 9510 Miniclinic Monitor@ showed a PPI of 852 ms and pulse duration of 0.76 ms. The electrocardiograph (Marquette Series 3300), when set at a speed of 25 mm/s, was found to be running at 22.9 mmls. The loss in speed was caused by reduction in diameter (and, hence, the reduction in speed) of the driver roller due to wear and usage. The follow-up ECG continued to show a PPI of 852 ms and the pacemaker is functioning well.
Slowing of the PPI is usually a sign of battery depletion. Increase and decrease in pacemaker rate would be a rather unusual complication. If this fluctuation in rate is found while measuring PPI on the ECG, the pacemaker should be analyzed using commercially available analyzers and the PPI confirmed. When an electrocardiograph records a significantly different PPI, it should be checked for proper roller speed before a decision is made about pacemaker malfunction.
Echocardiographic Detection of Free-Floating Left Atrial Thrombus
Starr-Edwards prosthesis had been placed for mitral stenosis; the patient was receiving warfarin, 7.5 mglday. After the trauma, a computed tomographic scan revealed a left parietooccipital hematoma, which was subsequently evacuated. Because of the intracranial hemorrhage, anticoagulation was discontinued. Examination 5 weeks after the accident disclosed atria1 fibrillation with a ventricular rate of
STEVEN W. TABAK, MD GERALD MAURER, MD
M-mode and 2-dimensional echocardiography have been used to diagnose left atria1 (LA) thrombi.1-3 LA thrombi are usually attached to the walk4y5free-floating thrombi are rare.6 We report a patient with a mitral valve prosthesis in whom a free-floating LA thrombus was detected echocardiographically and subsequently confirmed by emergency surgery for sudden prosthetic valve obstruction. A 52-year-old man entered the hospital after he sustained head trauma in a bicycle accident. Seven years earlier, a
From the Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, UCLA School of Medicine, 8700 Beverly Boulevard, Los Angeles, California 90048. Manuscript received August 8, 1983; revised manuscript received September 19, 1983, accepted September 26, 1983.
R
P
L
FIGURE 1. M-mode echocardiogram showing an enlarged left atrium containing a thrombus that moves without any obvious correlation to the cardiac cycle. Ao = aorta; LA = left atrium; RV = right ventricle.
January 15, 1984
THE AMERICAN JOURNAL OF CARDIOLOGY
Volume 53
375
FIGURE 2. Parasternal long-axis (left) and short-axis (right) P-dimensional echocardiograms demonstrating a thrombus within a large left atrial cavity (arrow). Ao = sot-tic root; AS = atrial septum; AV = aortic valve; LV = left ventricle, MP = mitral prosthesis; PV = pulmonic valve; RA = right atrium; RV = right ventricle; TV = tricuspid valve.
70 beatslmin. Normal prosthetic valve sounds were heard; no gallops or murmurs were present. Neurologic examination revealed mild right-sided hemiparesis. M-mode echocardiography (Fig. 1) demonstrated multiple dense lines moving erratically within an enlarged left atrium (59 mm). On 2-D echocardiography, the prosthetic valve moved normally. LA and right ventricular enlargement was present. A large (4 X 3 cm), almost globular LA mass (Fig. 2) was noted. It had not been present on echocardiography 3 months earlier. The patient was taken to the operating room the next morning. Just before induction of anesthesia, electromechanical dissociation developed; cardiopulmonary bypass was instituted emergently. Atriotomy revealed a spherical, smooth thrombus obstructing the mitral valve prosthesis.
LA thrombi often occur in patients with mitral stenosis or mitral valve prostheses4 and only rarely without mitral valve abnormalities.6 Prompt and accurate diagnosis is important because of the risk of complications. Emboli are common; sudden circulatory collapse may occur. Electromechanical dissociation due to obstruction of the mitral orifice has been described.2
Intermittent Ambulatory Dobutamine Infusions for Patients Awaiting Cardiac Transplantation JOHN Mcf3. HODGSON, MD MICHAEL AJA, MD RICHARD P. SORKIN, MD
Dobutamine is a useful inotropic agent for the treatment of severe left ventricular dysfunctionl; however, chronic administration has been limited due to tachy-
From the Department of Cardiology, Wayne County General Hospital, Westland, Michigan. Manuscript received June 24, 1983; revised manuscript received August 16, 1983, accepted August 20, 1983.
Two-dimensional echocardiography has become the noninvasive diagnostic procedure of choice for detecting intracardiac masses. Mural thrombi have a characteristic undulating motion,2 and can be differentiated from free-floating thrombi. This report suggests that lifethreatening LA thrombus formation can occur in patients with prosthetic valves even after relatively short interruptions of anticoagulant therapy. References 1. Schweizer P, Bardos P, Erbel R, Meyer J, Merx W, Messmer BJ, Efferl S. Detection of left atrial thrombi by echocardiography. Br Heart J 1981;45: 1488156. 2. Mike6 FL, Asinger RW, Rourke T, Hodges M, Sharma 6, Francis GS. Two-dimensional echocardiographic demonstration of left atrial thrombi in patients with prosthetic mitral valves. Circulation 1979;60:1183-1190. 3. Srkopiec RL, Torstveit JR, Prakash NS, Desser KB, Benchimol A. Noninvasive diagnosis of a free floating left atrial thrombus with emphasis on ;;pimensional echocardiographic features. Angiology 1983;34:1024. Ben-Shachar G, Vlodaver 2, Joyce LD, Edwards JE. Mural thrombosis of the left atrium following replacement of the mitral valve. J Thorac Cardiovasc Surg 1981;82:595-660. 5. Cipriano PR, Guthaner DF. Organized left atrial mural thrombus demonstrated by coronary angiography. Am Heart J 1978;96:166-169. 6. Sogaard PE. Free ball thrombus of the lefl atrium. Eur J Cardiol 1981;12: 177-179.
phylaxis and requirement for parenteral administration. Recently, the use of portable infusion pumps for the administration of various parenteral medications has become practical,-economical and safe.233 Applefeld et al3 reported 3 patients who successfully received intermittent outpatient dobutamine infusions with a portable pump. Their patients had been refractory to more conventional therapy and were maintained for several months with improved quality of life and minimal complications. We report the use of a similar program of intermittent ambulatory dobutamine infusion in a man who was awaiting cardiac transplantation. A 19-year-old man enjoyed excellent health and was a basketball and football star until the summer of 1982, when he contracted a presumed viral upper respiratory infection. Over several weeks, he developed progressive dypsnea on exertion, orthopnea, cough and fatigue. He was hospitalized
BRIEF REPORTS
FIGURE 1. A, leads VI to Vs recorded on a Fukuda electrocardiograph (model DU 3-S). showing a pulse-to-pulse interval (PPI) of 870 ms. B, leads I, II and III taken at the same time as in (A), but using a Marquette electrocardiograph machine (Series 3300) showing a PPI of 820 ms.
A
This was confirmed by taking ECGs on the 2 electrocardiograph machines during the same day (Fig. 1). Analysis of the pacemaker by a Medtronic Model 9510 Miniclinic Monitor@ showed a PPI of 852 ms and pulse duration of 0.76 ms. The electrocardiograph (Marquette Series 3300), when set at a speed of 25 mm/s, was found to be running at 22.9 mmls. The loss in speed was caused by reduction in diameter (and, hence, the reduction in speed) of the driver roller due to wear and usage. The follow-up ECG continued to show a PPI of 852 ms and the pacemaker is functioning well.
Slowing of the PPI is usually a sign of battery depletion. Increase and decrease in pacemaker rate would be a rather unusual complication. If this fluctuation in rate is found while measuring PPI on the ECG, the pacemaker should be analyzed using commercially available analyzers and the PPI confirmed. When an electrocardiograph records a significantly different PPI, it should be checked for proper roller speed before a decision is made about pacemaker malfunction.
Echocardiographic Detection of Free-Floating Left Atrial Thrombus
Starr-Edwards prosthesis had been placed for mitral stenosis; the patient was receiving warfarin, 7.5 mglday. After the trauma, a computed tomographic scan revealed a left parietooccipital hematoma, which was subsequently evacuated. Because of the intracranial hemorrhage, anticoagulation was discontinued. Examination 5 weeks after the accident disclosed atria1 fibrillation with a ventricular rate of
STEVEN W. TABAK, MD GERALD MAURER, MD
M-mode and 2-dimensional echocardiography have been used to diagnose left atria1 (LA) thrombi.1-3 LA thrombi are usually attached to the walk4y5free-floating thrombi are rare.6 We report a patient with a mitral valve prosthesis in whom a free-floating LA thrombus was detected echocardiographically and subsequently confirmed by emergency surgery for sudden prosthetic valve obstruction. A 52-year-old man entered the hospital after he sustained head trauma in a bicycle accident. Seven years earlier, a
From the Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, UCLA School of Medicine, 8700 Beverly Boulevard, Los Angeles, California 90048. Manuscript received August 8, 1983; revised manuscript received September 19, 1983, accepted September 26, 1983.
R
P
L
FIGURE 1. M-mode echocardiogram showing an enlarged left atrium containing a thrombus that moves without any obvious correlation to the cardiac cycle. Ao = aorta; LA = left atrium; RV = right ventricle.
January 15, 1984
THE AMERICAN JOURNAL OF CARDIOLOGY
Volume 53
375
FIGURE 2. Parasternal long-axis (left) and short-axis (right) P-dimensional echocardiograms demonstrating a thrombus within a large left atrial cavity (arrow). Ao = sot-tic root; AS = atrial septum; AV = aortic valve; LV = left ventricle, MP = mitral prosthesis; PV = pulmonic valve; RA = right atrium; RV = right ventricle; TV = tricuspid valve.
70 beatslmin. Normal prosthetic valve sounds were heard; no gallops or murmurs were present. Neurologic examination revealed mild right-sided hemiparesis. M-mode echocardiography (Fig. 1) demonstrated multiple dense lines moving erratically within an enlarged left atrium (59 mm). On 2-D echocardiography, the prosthetic valve moved normally. LA and right ventricular enlargement was present. A large (4 X 3 cm), almost globular LA mass (Fig. 2) was noted. It had not been present on echocardiography 3 months earlier. The patient was taken to the operating room the next morning. Just before induction of anesthesia, electromechanical dissociation developed; cardiopulmonary bypass was instituted emergently. Atriotomy revealed a spherical, smooth thrombus obstructing the mitral valve prosthesis.
LA thrombi often occur in patients with mitral stenosis or mitral valve prostheses4 and only rarely without mitral valve abnormalities.6 Prompt and accurate diagnosis is important because of the risk of complications. Emboli are common; sudden circulatory collapse may occur. Electromechanical dissociation due to obstruction of the mitral orifice has been described.2
Intermittent Ambulatory Dobutamine Infusions for Patients Awaiting Cardiac Transplantation JOHN Mcf3. HODGSON, MD MICHAEL AJA, MD RICHARD P. SORKIN, MD
Dobutamine is a useful inotropic agent for the treatment of severe left ventricular dysfunctionl; however, chronic administration has been limited due to tachy-
From the Department of Cardiology, Wayne County General Hospital, Westland, Michigan. Manuscript received June 24, 1983; revised manuscript received August 16, 1983, accepted August 20, 1983.
Two-dimensional echocardiography has become the noninvasive diagnostic procedure of choice for detecting intracardiac masses. Mural thrombi have a characteristic undulating motion,2 and can be differentiated from free-floating thrombi. This report suggests that lifethreatening LA thrombus formation can occur in patients with prosthetic valves even after relatively short interruptions of anticoagulant therapy. References 1. Schweizer P, Bardos P, Erbel R, Meyer J, Merx W, Messmer BJ, Efferl S. Detection of left atrial thrombi by echocardiography. Br Heart J 1981;45: 1488156. 2. Mike6 FL, Asinger RW, Rourke T, Hodges M, Sharma 6, Francis GS. Two-dimensional echocardiographic demonstration of left atrial thrombi in patients with prosthetic mitral valves. Circulation 1979;60:1183-1190. 3. Srkopiec RL, Torstveit JR, Prakash NS, Desser KB, Benchimol A. Noninvasive diagnosis of a free floating left atrial thrombus with emphasis on ;;pimensional echocardiographic features. Angiology 1983;34:1024. Ben-Shachar G, Vlodaver 2, Joyce LD, Edwards JE. Mural thrombosis of the left atrium following replacement of the mitral valve. J Thorac Cardiovasc Surg 1981;82:595-660. 5. Cipriano PR, Guthaner DF. Organized left atrial mural thrombus demonstrated by coronary angiography. Am Heart J 1978;96:166-169. 6. Sogaard PE. Free ball thrombus of the lefl atrium. Eur J Cardiol 1981;12: 177-179.
phylaxis and requirement for parenteral administration. Recently, the use of portable infusion pumps for the administration of various parenteral medications has become practical,-economical and safe.233 Applefeld et al3 reported 3 patients who successfully received intermittent outpatient dobutamine infusions with a portable pump. Their patients had been refractory to more conventional therapy and were maintained for several months with improved quality of life and minimal complications. We report the use of a similar program of intermittent ambulatory dobutamine infusion in a man who was awaiting cardiac transplantation. A 19-year-old man enjoyed excellent health and was a basketball and football star until the summer of 1982, when he contracted a presumed viral upper respiratory infection. Over several weeks, he developed progressive dypsnea on exertion, orthopnea, cough and fatigue. He was hospitalized