P1312 Implications of a large atrial roof thrombus

Abstract

Abstract Funding Acknowledgements No funding Introduction Rheumatic heart disease is the most common cause of mitral valve stenosis. Rheumatic valve disease presents a strong predisposing factor to intracardiac thrombi formation in the left atrium, particularly when there is a background of atrial fibrillation. The predominant location for thrombus creation is the left atrial appendage, due to its morphology, and rarely the free wall or roof of the left atrium. In either case, the presence of intracardiac thrombi in the left cardiac cavities poses a severe risk factor for systemic embolism which can prove detrimental for the patient leading to increased morbidity and mortality. Transesophageal echocardiography remains the gold standard for screening of the left atrium. Case presentation We present the case of a 72 year old woman who was admitted to the Emergency Department of our Hospital because of palpitations and progressive weakness over the last month. She had a known history of rheumatic mitral valve stenosis and chronic atrial fibrillation under standard anticoagulant treatment with acenocoumarol. Methods - Results: On admission, the patient was hemodynamically stable without signs of heart failure. The electrocardiogram revealed atrial fibrillation with a ventricular rate of approximately 135 bpm. Chest X-Ray did not demonstrate any signs of pulmonary congestion. Blood tests were normal, except from a subtherapeutic INR 1.3. Transthoracic echocardiography depicted a suspicious large echogenous mass located on the posterior wall of the left atrium. Furthermore, there was severe mitral valve stenosis with calcification of the mitral annulus as well as reduced mobility of the leaflets (Mitral Valve Area ∼0.8 cm2, Mean gradient = 15 mmHg) and mild aortic valve stenosis. The left ventricle had normal dimensions and good overall systolic function. Systolic pulmonary pressure was estimated at 50 mmHg. Transesophageal echocardiography confirmed the presence of a large echogenous mass (2,6 x 2,9 cm) located on the posterior wall of the left atrium between the right and left pulmonary veins as well as another mass at the left atrial appendage. Contrast echocardiography ensued, which revealed no absorption of the contrast medium by the mass thus suggesting a lesion with no vascularity, compatible with thrombus. Furthermore there was diffuse slow flow within the left atrium (smoke) indicating blood stasis. The patient was treated with a cardioselective beta blocker and combination of aspirin and acenocoumarol with a target INR of 2,5-3 and was referred for cardiothoracic consultation. Conclusion/Discussion: We describe a rare case of moderate mitral stenosis with presence of a large thrombus with mobile parts in an unusual location. In this setting the indication for surgery (mitral valve replacement) is upgraded since there is increased risk of thrombus detachment and debilitating systemic embolism. Abstract P1312 Figure.