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Two-dimensional echocardiographic features of floating left atrial thrombus
March 1, 1986
visible, and the frequency of this vibration and of the low-pitched murmur was identical (Fig. 2). No evidence of ruptured aortic cusps was seen by 2-dimensional echocardiography. Diastolic separation of the aortic cusps gradually increased as the low-frequency murmur became louder. No abnormal flow corresponding to the low-pitched murmur could be detected in the pulsed Doppler echocardiogram recorded below the aortic cusps. The pressure curve of the ascending aorta recorded with a Mikrotip angiocatheter@and that of the left ventricular cavity recorded
with a Sones catheter were superimposed for evaluation of the mechanism of this murmur. The lowpitched murmur was recorded when the diastolic pressure gradient between the ascending aorta and the left ventricle was below 15 mm Hg (Fig. 3). This diastolic whoop lasted for as long as 40 months after recurrence of atrial fibrillation. Musical diastolic murmurs have been described in AR due to syphilis, infective endocarditis and rheumatic valvular diseases coinciding with AR.1r4-6The diastolic whoop in our patient consistently appeared only in the late diastolic phase of long cardiac cycles when the pressure gradient between the aorta and the left ventricle was minimal, and it was not related to the diastolic blowing murmur due to AR. During sinus rhythm of 80 beats/min, this diastolic whoop was not
Two-DimensionalEchocardiographic Features of Floating left Atrial Thrombus TSUI L. HSU, MD CHIN C. CHEN, MD CHUNG Y. CHEN, MD MING C. HSIUNG, MD BENJAMIN N. CHIANG, MD
W
e report a case of a floating left atria1 [LA) thrombus diagnosed by echocardiography (echo) and describe Doppler features of the mitral flow pattern. A 31-year-old women with a history of rheumatic heart disease was admitted to the hospital because she From the Department of Medicine, Division of Cardiology, Veterans General Hospital, Taipei, Taiwan, Republic of China. This work was supported in part by Clinical Research Center, Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan. Manuscript received June 11, 1985; revised manuscript received July 18,1985, accepted July 22,1985.
THE AMERICAN
JOURNAL
OF CARDIOLOGY
Volume 57
701
audible. The above findings indicate that this whoop is entirely different from the musical diastolic murmurs reported previously. We believe that this whoop originates from vibrations of the aortic valve, but that this occurrence results from interaction of the diastolic pressure gradient, velocity of regurgitant flow, quality of the aortic valve and the extent of cuspal separation. When the diastolic gradient falls below 15 mm Hg, the velocity of the regurgitant flow diminishes and the regurgitant flow at that gradient causes vibration of the soft and suitably separated aortic cusps. When the diastolic gradient is reduced even more, the aortic valve does not develop vibration with the disappearance of regurgitant flow. The whoop is probably intensified by the resonance in the enlarged aortic cusps. This diastolic whoop would probably appear in all beats during bradycardia.
References 1. Sheikh MU, Lee WR, Mills RJ, Dais K. Musical murmurs: clinical impiications, long-term prognosis, andecho-phonocardiogrophic features. Am Heart f l984;108:377-386. 2. Keenan TJ, Schwartz MJ. Tricuspid whoop. Am J Cordial 1973;31:642-645. 3. Felner JM, Harwood S, Mond H, Plauth W, Brinsfield D, Schlant RC. Systolic honks in young children. Am 1 Cardiol 1977;40:206-211, 4. Gelfand D, Bellet S. The muscial murmur of aortic insufficiency: Clinical manifestations; based on o study of 18 cases.Am f Med Sci 1951:221:644-654. 5. Chandraratna PAN, Samet P, Robinson MJ, Byrd C. Echocardiogrophy of the fIoopy aortic valve. Report of (I case. Circulation 1975;52:959-962. 6. Venkataraman K, Bornheimer JF, Pontius S, Kim SJ, Allen JW. Diastolic flutter of aortic valves in aortic regurgitation: a report of seven cases.Angiolo-
gy 1979;30:297-303.
had progressive exertional dyspnea and orthopnea. Examination revealed an accentuated first heart sound, opening snap and grade 3/6 diastolic rumbling murmur at the apex. Bilateral basal pulmonary rales were present. The electrocardiogram showed sinus rhythm, P mitrale, and biventricular hypertrophy. The chest radiograph showed cardiomegaly with a prominent LA shadow. M-mode and Z-dimensional elcho was typical of mitral stenosis but in addition disclosed a large free-floating LA thrombus. Frequently, the LA thrombus lodged within the mitral valve orifice (Fig. I), and the Z-dimensional Doppler echo study of mitral flow showed variable disappearance of mitral flow during diastole whenever the circulating mass was seen in the vicinity of the mitral valve (Fig. 2). Surgery confirmed the presence of a large thrombus lying freely within the LA cavity. Floating LA thrombus is uncommon. Because of its potential in causing a fatal systemic emboli or mitral valve orifice occlusion, which may result in sudden death, early diagnosis is obviously important1 The characteristic echo findings have been well established.z,3 While clinical auscultation may show variable changes in the intensity of the diastolic murmur,4,5 Z-dimensional Doppler echo further documents the acute hemodynamic alteration that may occur.
702
BRIEF REPORTS
FIGURE 1. Parasternal long-axis cross section of the heart. A and 6, a highly mobile left atrial thrombus. The thrombus lodges within the mitral valve orifice (A). C, M-mode echocardiogram showing band-like echoes of a floating thrombus, which moves to obstruct the left ventricular inflow tract.
FIGURE 2. Recording with continuous-wave Doppler across the mitral valve shows variable disappearance of mitral flow during diastole. The second beat in panel /3 shows total disappearance of diastolic mitral flow.
References 1. Lie JT, Entman ML. “Hole-in one” sudden death: mitral stenosis and left atria1 ball thrombus. Am Heart J 1976;91:798-804, . 2. Sunagawa K, Orita Y, Tanaka S, Kikuchi Y, Nakamura M, Hirata T. Left otrial ball thrombus diagnosed by two-dimensional echocardiography. Ah Heart 1 1980;100:89-94.
3. Furukawa K, Katsume H. Matsukubo H, Inoue D. Echocardiographic findings of floating thrombus in left atrium. Br Heart J 1980;44:599-601. 4. Chen CC, Hsiung MC, Chiang BN. Variable diastolic rumbling murmur caused by floating left atrial thrombus. Br Heart J 1983;50:190-192. 5. Warda M, Garcia 1. Pechacek LW, Massumkhani A. Hall RI. Auscultatorv and echocardiograp6ic features of mobile left atrial thromb& JACC 1985; 5:379-382.
visible, and the frequency of this vibration and of the low-pitched murmur was identical (Fig. 2). No evidence of ruptured aortic cusps was seen by 2-dimensional echocardiography. Diastolic separation of the aortic cusps gradually increased as the low-frequency murmur became louder. No abnormal flow corresponding to the low-pitched murmur could be detected in the pulsed Doppler echocardiogram recorded below the aortic cusps. The pressure curve of the ascending aorta recorded with a Mikrotip angiocatheter@and that of the left ventricular cavity recorded
with a Sones catheter were superimposed for evaluation of the mechanism of this murmur. The lowpitched murmur was recorded when the diastolic pressure gradient between the ascending aorta and the left ventricle was below 15 mm Hg (Fig. 3). This diastolic whoop lasted for as long as 40 months after recurrence of atrial fibrillation. Musical diastolic murmurs have been described in AR due to syphilis, infective endocarditis and rheumatic valvular diseases coinciding with AR.1r4-6The diastolic whoop in our patient consistently appeared only in the late diastolic phase of long cardiac cycles when the pressure gradient between the aorta and the left ventricle was minimal, and it was not related to the diastolic blowing murmur due to AR. During sinus rhythm of 80 beats/min, this diastolic whoop was not
Two-DimensionalEchocardiographic Features of Floating left Atrial Thrombus TSUI L. HSU, MD CHIN C. CHEN, MD CHUNG Y. CHEN, MD MING C. HSIUNG, MD BENJAMIN N. CHIANG, MD
W
e report a case of a floating left atria1 [LA) thrombus diagnosed by echocardiography (echo) and describe Doppler features of the mitral flow pattern. A 31-year-old women with a history of rheumatic heart disease was admitted to the hospital because she From the Department of Medicine, Division of Cardiology, Veterans General Hospital, Taipei, Taiwan, Republic of China. This work was supported in part by Clinical Research Center, Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan. Manuscript received June 11, 1985; revised manuscript received July 18,1985, accepted July 22,1985.
THE AMERICAN
JOURNAL
OF CARDIOLOGY
Volume 57
701
audible. The above findings indicate that this whoop is entirely different from the musical diastolic murmurs reported previously. We believe that this whoop originates from vibrations of the aortic valve, but that this occurrence results from interaction of the diastolic pressure gradient, velocity of regurgitant flow, quality of the aortic valve and the extent of cuspal separation. When the diastolic gradient falls below 15 mm Hg, the velocity of the regurgitant flow diminishes and the regurgitant flow at that gradient causes vibration of the soft and suitably separated aortic cusps. When the diastolic gradient is reduced even more, the aortic valve does not develop vibration with the disappearance of regurgitant flow. The whoop is probably intensified by the resonance in the enlarged aortic cusps. This diastolic whoop would probably appear in all beats during bradycardia.
References 1. Sheikh MU, Lee WR, Mills RJ, Dais K. Musical murmurs: clinical impiications, long-term prognosis, andecho-phonocardiogrophic features. Am Heart f l984;108:377-386. 2. Keenan TJ, Schwartz MJ. Tricuspid whoop. Am J Cordial 1973;31:642-645. 3. Felner JM, Harwood S, Mond H, Plauth W, Brinsfield D, Schlant RC. Systolic honks in young children. Am 1 Cardiol 1977;40:206-211, 4. Gelfand D, Bellet S. The muscial murmur of aortic insufficiency: Clinical manifestations; based on o study of 18 cases.Am f Med Sci 1951:221:644-654. 5. Chandraratna PAN, Samet P, Robinson MJ, Byrd C. Echocardiogrophy of the fIoopy aortic valve. Report of (I case. Circulation 1975;52:959-962. 6. Venkataraman K, Bornheimer JF, Pontius S, Kim SJ, Allen JW. Diastolic flutter of aortic valves in aortic regurgitation: a report of seven cases.Angiolo-
gy 1979;30:297-303.
had progressive exertional dyspnea and orthopnea. Examination revealed an accentuated first heart sound, opening snap and grade 3/6 diastolic rumbling murmur at the apex. Bilateral basal pulmonary rales were present. The electrocardiogram showed sinus rhythm, P mitrale, and biventricular hypertrophy. The chest radiograph showed cardiomegaly with a prominent LA shadow. M-mode and Z-dimensional elcho was typical of mitral stenosis but in addition disclosed a large free-floating LA thrombus. Frequently, the LA thrombus lodged within the mitral valve orifice (Fig. I), and the Z-dimensional Doppler echo study of mitral flow showed variable disappearance of mitral flow during diastole whenever the circulating mass was seen in the vicinity of the mitral valve (Fig. 2). Surgery confirmed the presence of a large thrombus lying freely within the LA cavity. Floating LA thrombus is uncommon. Because of its potential in causing a fatal systemic emboli or mitral valve orifice occlusion, which may result in sudden death, early diagnosis is obviously important1 The characteristic echo findings have been well established.z,3 While clinical auscultation may show variable changes in the intensity of the diastolic murmur,4,5 Z-dimensional Doppler echo further documents the acute hemodynamic alteration that may occur.
702
BRIEF REPORTS
FIGURE 1. Parasternal long-axis cross section of the heart. A and 6, a highly mobile left atrial thrombus. The thrombus lodges within the mitral valve orifice (A). C, M-mode echocardiogram showing band-like echoes of a floating thrombus, which moves to obstruct the left ventricular inflow tract.
FIGURE 2. Recording with continuous-wave Doppler across the mitral valve shows variable disappearance of mitral flow during diastole. The second beat in panel /3 shows total disappearance of diastolic mitral flow.
References 1. Lie JT, Entman ML. “Hole-in one” sudden death: mitral stenosis and left atria1 ball thrombus. Am Heart J 1976;91:798-804, . 2. Sunagawa K, Orita Y, Tanaka S, Kikuchi Y, Nakamura M, Hirata T. Left otrial ball thrombus diagnosed by two-dimensional echocardiography. Ah Heart 1 1980;100:89-94.
3. Furukawa K, Katsume H. Matsukubo H, Inoue D. Echocardiographic findings of floating thrombus in left atrium. Br Heart J 1980;44:599-601. 4. Chen CC, Hsiung MC, Chiang BN. Variable diastolic rumbling murmur caused by floating left atrial thrombus. Br Heart J 1983;50:190-192. 5. Warda M, Garcia 1. Pechacek LW, Massumkhani A. Hall RI. Auscultatorv and echocardiograp6ic features of mobile left atrial thromb& JACC 1985; 5:379-382.