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(Circulation. 1998;97:1647.)
© 1998 American Heart Association, Inc.

Images in Cardiovascular Medicine

Floating Mobile Mass That Is Probably Thrombus

A Life-Threatening Complication of Mitral Stenosis

Chuwa Tei, MD; ; Fletcher A. Miller, MD

From the Division of Cardiovascular Disease, Mayo Clinic and Mayo Foundation, Rochester, Minn.

Correspondence to Chuwa Tei, MD, Department of Rehabilitation and Physical Medicine, Kagoshima University, Kagoshima, 890, Japan.

A 52-year-old woman presented with palpitations, progressive shortness of breath, and transient dizziness during the week preceding this echocardiographic study. Physical examination was typical for mitral stenosis, with an irregular heart rate of 78 bpm, accentuated first heart sound, opening snap, and apical diastolic rumble. The ECG demonstrated atrial fibrillation. Two-dimensional (2D) echocardiographic images from the parasternal and apical positions are shown in the upper and lower panels of the Figure respectively, and an M-mode recording through the mitral valve and left atrium is also shown in the lower panel. The mitral leaflets were thickened and tethered, and there was a reduced E-F slope on the M-mode image, all consistent with rheumatic mitral stenosis. In addition, a left atrial mass was identified within the left atrium. This had no attachment site during systolic cycles (B) on 2D imaging. The mass floated freely within the left atrium. Floating thrombus constitutes a surgical emergency. The lethal potential of this floating thrombus was underscored by intermittent lodging in the mitral orifice during diastole (B on 2D images and fourth beat on M-mode image). Urgent surgery was recommended, but she declined for religious reasons. She died suddenly, 10 hours after the echocardiographic examination.

View larger version (143K): [in this window] [in a new window]   Figure 1. Top, parasternal two-dimensional echocardiographic images at end diastole (A) and end systole (B). Ball thrombus (TH) protrudes across mitral orifice in diastole. Bottom, Apical two-dimensional echocardiographic image at end diastole (A) and end systole (B) and M-mode echocardiogram of anterior mitral leaflet and left atrium (LA) recorded from apex. . . . [Full Text of this Article]