Abstract
BackgroundLeft atrial septal pouches (LASPs) are a relatively newly described but common anatomical cardiac variant thought to be associated with atrial fibrillation (AF) and cardio-embolic stroke. Blue toe syndrome (BTS) describes ischemic changes in the toes due to microembolisation of the digital arteries. Establishing the etiology of BTS is vital so that the underlying cause can be treated. Here we describe the first case of BTS arising due to emboli from LASP thrombus arising on a background of new-onset AF.Case presentationA 65-year-old man presented with a two-day history of progressive painful swelling and bluish-purple discoloration of the second and fourth toes of his left foot and new-onset AF. Tests for hypercoagulability disorders were negative. Duplex ultrasound and CT angiography excluded deep venous thrombosis and an absence of embolus, thrombus, or occlusion in the arterial tree in the lower extremities bilaterally, so BTS was diagnosed. While transthoracic echocardiography and chest CT initially showed no cardiac abnormalities or mural thrombus, subsequent transesophageal echocardiography revealed a LASP with an associated pedunculated thrombus. The affected toes were amputated due to wet gangrene, but the patient recovered well with thrombus resolution after anticoagulation.ConclusionThe presence of a LASP in the absence of any other identifiable cause of BTS should trigger careful investigation of the interatrial septum, preferably using a multimodality imaging approach. The possibility that LASPs may not merely be an innocent bystander but a causative mechanism for peripheral ischemia must be considered.
Highlights
Left atrial septal pouches (LASPs) are a relatively newly described but common anatomical cardiac variant thought to be associated with atrial fibrillation (AF) and cardio-embolic stroke
Given the high index of suspicion of an intracavitary thrombus in the setting of new-onset AF and progression of the cyanotic toes, the patient was referred to cardiology, where transesophageal echocardiography (TEE) revealed an anomalous LASP and a 7.7 × 3 mm mobile ovoid echodense mass with a narrow stalk attached to the pouch, suggestive of thrombus (Fig. 4, Supplemental Video 1)
The LASP, together with new-onset AF, were likely to have resulted in thrombus formation within the septal pouch with subsequent embolization to the digital artery of the left foot to cause Blue toe syndrome (BTS)
Summary
The presence of a LASP in the absence of any other identifiable cause of BTS should trigger careful investigation of the interatrial septum, preferably using a multimodality imaging approach. Given the high index of suspicion of an intracavitary thrombus in the setting of new-onset AF and progression of the cyanotic toes, the patient was referred to cardiology, where transesophageal echocardiography (TEE) revealed an anomalous LASP and a 7.7 × 3 mm mobile ovoid echodense mass with a narrow stalk attached to the pouch, suggestive of thrombus (Fig. 4, Supplemental Video 1). The LASP, together with new-onset AF, were likely to have resulted in thrombus formation within the septal pouch with subsequent embolization to the digital artery of the left foot to cause BTS
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