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Circulation. 2006;114:e513-e514
doi: 10.1161/CIRCULATIONAHA.106.617886
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(Circulation. 2006;114:e513-e514.)
© 2006 American Heart Association, Inc.

Images in Cardiovascular Medicine

The Case of a Disappearing Left Atrial Appendage Thrombus

Direct Visualization of Left Atrial Thrombus Migration, Captured by Echocardiography, in a Patient With Atrial Fibrillation, Resulting in a Stroke

Amit Parekh, MD; Radhika Jaladi, MD; Sushant Sharma, MD; William A. Van Decker, MD; Michael D. Ezekowitz, MBChB, DPhil

From the Lankenau Institute for Medical Research, Wynnewood, Pa (A.P., M.D.E.); Drexel University College of Medicine, Philadelphia, Pa (R.J.); Department of Cardiology, Ochsner Clinic Foundation, New Orleans, La (S.S.); and the Division of Cardiology, Temple University School of Medicine, Philadelphia, Pa (W.A.V.D.).

Correspondence to Michael D. Ezekowitz, MBChB, DPhil, Vice-President, Lankenau Institute for Medical Research, 100 Lancaster Ave, Wynnewood, PA 19096-3425. E-mail ezekowitzm{at}mlhs.org

A 53-year-old female with atrial fibrillation underwent transesophageal echocardiography for a suspected cardiac source of a thromboembolic episode. A thrombus was identified in the left atrial appendage. During the transesophageal echocardiography, the thrombus disappeared, under direct visualization, from the left atrial appendage. Four hours later, the patient developed a stroke. We believe that this is the first case describing direct visualization of left atrial thrombus migration in the English-language literature. Sequential frames are shown in the Figure.


Figure 1178225
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  		Sequential transesophageal echocardiography images demonstrating migration of left atrial appendage (LAA) thrombus. A, The 2x1-cm thrombus (T) in the left atrial appendage. B, The thrombus migrating out of the LAA orifice. C, The thrombus visualized in the body of the left atrium (LA). D, The thrombus is no longer visible in the heart.

The development of neurological symptoms 4 hours (rather than immediately) after visualized thrombus migration is of interest. The luminal diameter of the internal carotid artery is highly variable, but it is unlikely that a 2x1-cm thrombus entered the carotid artery system. We hypothesize that the observed clot migration was not the culprit event but that there were subsequent emboli, despite a therapeutic activated partial thromboplastin time level of intravenous unfractionated heparin, resulting in the stroke. Data from carotid artery stenting studies1,2 suggest that this time interval is somewhere in the range of a few minutes to a few hours, which is consistent with the time line of events seen in our patient.


*    Disclosures
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Dr Van Decker has received grants from GE Healthcare Nuclear Imaging and Oncology Chemotherapeutic Protocols and has served on the speakers bureau for and received honoraria from Molecular insights. The other authors report no conflicts.


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  1. Tan KT, Cleveland TJ, Berczi V, McKevitt FM, Venables GS, Gaines PA. Timing and frequency of complications after carotid artery stenting: what is the optimal period of observation? J Vasc Surg. 2003; 38: 236–243.[CrossRef][Medline] [Order article via Infotrieve]
  2. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001; 357: 1729–1737.[CrossRef][Medline] [Order article via Infotrieve]

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Circulation 2006 114: 1343. [Full Text]



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S. Habara, K. Dote, M. Kato, S. Sasaki, K. Goto, H. Takemoto, D. Hasegawa, and O. Matsuda
Prediction of left atrial appendage thrombi in non-valvular atrial fibrillation
Eur. Heart J., September 2, 2007; 28(18): 2217 - 2222.
[Abstract] [Full Text] [PDF]

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