Floating Left Atrial Thrombus

Abstract

A 70-year-old woman with a 3-year history of atrial fibrillation and heart failure NYHA class III presented to the emergency department with palpitations, worsening shortness of breath and anterior epistaxis. Physical examination demonstrated rapid atrial fibrillation, a grade 2/6 holosystolic murmur of mitral valve regurgitation, a grade 3/6 murmur of tricuspid regurgitation and lower extremities swelling. Two-dimensional transthoracic echocardiography revealed a thickened mitral valve with regurgitant flow and a round mass, 18 mm in diameter, moving about randomly in the left atrium, attached to the interatrial septum by a pediculum, reaching the mitral annulus plane. The mass was well demarcated with slight irregularity of its borders; also, tricuspid regurgitation with maximum gradient 30 mmHg, intact interatrial septum, akinesia of the basal two-thirds of the inferior wall and ejection fraction of 42% were noted. Transesophageal echocardiography confirmed the intraatrial thrombus. The coagulation parameters were normal and the epistaxis was considered to be due to heart failure with increase in venous pressure. The patient refused surgery and received anticoagulant therapy (fraxiparine 0.6 ml/day) for 3 weeks, after the otolaryngologist stopped the epistaxis by anterior nasal packing. After 3 weeks, the transthoracic echocardiography was repeated with no sign of atrial thrombus. In this case, left atrial thrombus formation could be explained by the presence of atrial fibrillation.