(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. LA is enlarged,
and appearance of mitral valve is typical for rheumatic
stenosis. Appearance of thrombus resembles left atrial myxoma
on end-diastolic images. However, during systole, it was
seen to float freely within atrium. On M-mode image, unlike a myxoma,
thrombus does not move to and fro with each cycle. Rather, it has a
hectic motion within atrium, intermittently lodging in mitral orifice
(fourth beat). RV indicates right ventricle.
|
|
Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
