Abstract

A 69-year-old gentleman with history of obstructive sleep apnoea, asthma, hypertension and chronic kidney disease presented with several-week history of symptoms consistent with NYHA class III heart failure. His ECG showed sinus rhythm with no ischaemic changes and blood tests showed Hs-TnT 32 ng/L, NT-proBNP 210 pmol/L and a normal coagulation screen. Transthoracic echocardiogram revealed a large mobile thrombus measuring 35 mm x 11 mm in the left atrial appendage (LAA) prolapsing into the left ventricle during diastole and a moderate size thrombus at the apex of the left ventricle. His left ventricular systolic function was moderately impaired with multiple regional wall abnormalities. Coronary angiogram showed severe triple vessel disease. Warfarin was commenced in addition to evidence based heart failure medications. Sinus rhythm was recorded throughout his inpatient stay. Repeat transthoracic echocardiography a week later showed complete resolution of the two thrombi. The plan for him was to complete a period of anticoagulation, continue anti-failure medications and to go forward for surgical revascularisation. LAA is the source of thrombus formation in up to 90% of cardioembolic stroke cases in non-valvular AF. In valvular AF, more than half of the thrombi are located in the atrial cavity rather than the LAA. Detecting a thrombus in the LAA in the presence of sinus rhythm is rare. To detect a thrombus in the LAA with transthoracic echocardiogram in a patient with sinus rhythm and only moderately impaired LV function to our knowledge hasn’t been reported in literature previously.

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