Free-floating Thrombus Research Articles

Large free-floating left atrial thrombus with normal mitral valve

Left atrial thrombus in the presence of diseased mitral valve and atrial fibrillation is a well known entity. But it is very rare to occur in the presence of normal mitral valve apparatus. We report the case of a 36 year old female who presented with left atrial ball valve thrombus and normal mitral valve apparatus and underwent surgery. This patient with gangrene of right lower limb came for cardiac evaluation. She had infarct in left middle cerebral artery territory- ten months prior to this admission and was on treatment for infertility. She had atrial fibrillation. Emergency surgery to remove the thrombus should be considered given its potential life threatening embolic nature.

Occurrence of Simultaneous Left Ventricular Mural Thrombus and a Fresh Floating Thrombus in the Left Common Carotid Artery

Stroke is the third-leading cause of death in the United States after cardiovascular disease and cancer. It remains the leading cause of serious long-term disability in the United States. Mechanisms of ischemic stroke include embolism, decreased perfusion, and thrombosis. Cardio-embolism, defined as a source of embolus originating from the heart, may account for an estimated 20% of ischemic strokes. Intracavity thrombus from wall motion abnormalities, especially in the first 2 weeks after anterior myocardial infarction, has been described as a potential cardiac source of emboli. The finding of an LV apical thrombus detected by transthoracic echocardiography as a possible embolic source and the simultaneous discovery of a fresh floating thrombus in the left common carotid artery as detected by duplex ultrasonography are rare findings. We report a case of a 77-year-old man with both of these findings with signs and symptoms of a myocardial infarction with late presentation. Trans-thoracic echocardiography revealed an echo density consistent with mural thrombus that was located adjacent to the severely hypokinetic left ventricular apical wall. A carotid duplex revealed a totally occluded left common carotid artery with an echo density suggestive of thrombus. Atheromatous deposits in the extra-cranial carotid arteries may cause localized thrombosis. However, a free-floating thrombus in the carotid artery could be a result of a cardiac source of embolism. Cardioembolic syndromes typically presents as emergencies. Prompt diagnosis and urgent optimal medical and surgical treatments are warranted because these patients have an increased risk for distal embolization and vessel occlusion that lead to severe disability or death.

Therapeutic Approach in Patients with a Floating Thrombus in the Right Heart

BackgroundThe occurrence of a floating thrombus in the right heart, although rare, is a life-threatening condition requiring a specific approach. In most cases, these thrombi are a result of embolization from deep venous thrombosis, and have lodged temporarily in the right heart. The management of this condition is variable, depending on whether or not there is a thrombus entrapped within a foramen ovale (FO). ObjectivesTo present the management of 2 patients with a free-floating thrombus in the right heart, and a third patient with an entrapped thrombus in the FO. Case ReportsTwo patients with a free-floating thrombus in the right atrium who were treated with thrombolytic therapy had an immediate excellent outcome. The patient with a thrombus entrapped within the FO was scheduled for surgical removal of the thrombus due to an unacceptable risk of systemic embolization if treated with thrombolytic and anticoagulant therapy. Unfortunately, he developed an ischemic stroke on the fifth day of presentation, just a few hours before the scheduled surgery, despite meticulous monitoring of continuous heparin infusion with activated partial thromboplastin time. ConclusionThrombolytic therapy is recommended in patients with a free-floating thrombus in the right heart. However, in patients with a thrombus entrapped within an FO, delaying surgical removal of the thrombus may be deleterious due to unpredictable systemic embolization.

Ultrasound in free-floating thrombus of the carotid artery: the best diagnostic tool to detect this under estimated condition?

A 102-year-old woman with unremarkable medical history presented to our institution with left sided hemiparesis, of two day duration (NIHSS = 5). EKG, blood and urine tests, including coagulation parameters, were within normal limits. Brain computed tomography (CT) revealed an ischemic lesion in the right middle cerebral artery territory. Duplex ultrasound of the cervical vessels evidenced a hyperechoic mobile thrombus, moving in cyclical motion with the cardiac cycles, attached to the arterial wall in the right internal carotid artery extending to common carotid artery (Fig. 1a, b and video as supplemental material on web-page) and reverberating/oscillating flow was observed on Doppler spectral analysis (Fig. 1c), suggestive of a freefloating thrombus (FFT). Extensive coagulation studies

Percutaneous treatment of a free-floating thrombus in the right atrium of a patient with pulmonary embolism and acute myocarditis

Free-floating thrombi in the right atrium (RA) are extremely hazardous to patients with pulmonary thromboembolism, and optimal treatment methods remain unclear. We report a case of successful percutaneous intervention of a critical right atrial thrombus. The patient was a 50-year-old woman who had been under medication for acute myocarditis when she complained of sudden severe dyspnea. Echocardiography showed a mobile snake-like thrombus in the RA. The thrombus was pulled back to the distal inferior vena cava (IVC) using a catheter and an IVC filter was placed. Percutaneous treatment is useful for treating free-floating RA thrombi.

Free-Floating Thrombus of the Carotid Artery Detected on Carotid Ultrasound in Patients with Cerebral Infarcts: A 10-Year Study

Free-Floating Thrombus of the Carotid Artery Detected on Carotid Ultrasound in Patients with Cerebral Infarcts: A 10-Year Study

Computed tomography angiography evaluation of internal carotid artery free-floating thrombus—single-center diagnosis, false-positives, and follow-up

The incidence and management of free-floating thrombus (FFT), also known as intraluminal carotid thrombus, within the internal carotid artery (ICA) are currently unknown. The first case series documenting FFT was published in 1966 [1]. There have been numerous case series publications describing FFT using various modalities mostly including angiography, duplex ultrasound (DU), and more recently computed tomography (CT). Based on retrospective studies, its incidence is estimated to be between 0.4–0.7 % and 0.05 % at cerebral angiography and DU, respectively [2–4]. A more recent single-center retrospective analysis using CT angiography (CTA) quoted the incidence at 3.1 % [5]. With current guidelines for imaging of acute stroke and transient ischemic attack, CTA and magnetic resonance imaging angiography are more frequently being performed in the urgent setting [6]. More than 90 % of patients with FFT develop neurologic sequelae [7]. The “donut sign” has been used to describe the appearance of FFT in the axial plane on CTA [5]. Further characterization of FFT is possible with multiplanar reformatted images and may help distinguish FFT from other mimickers. We present the CTA findings of FFT and describe its potentially unstable clinical course and its resolution on imaging after treatment. Potential false-positives, including complex ulcerated plaque, will be discussed.

Free-floating giant left atrial ball thrombus with aortic valve disease--a rare entity and a near miss

Large left atrial mural thrombi in the absence of mitral valve stenosis have been reported rarely in the literature. It is even rarer without history of atrial fibrillation (AF). These masses can cause systemic embolization and sudden circulatory collapse when they obstruct the mitral valve. We are presenting a case of giant, free floating ball thrombus, detected after aortic valve replacement for mixed aortic valve disease. It was found immediately before separation from cardiopulmonary bypass by transoesophageal echocardiography and was successfully removed. A ball thrombus without mitral valve disease and AF with aortic valve disease is not yet reported in the literature.

Massive Pulmonary Embolism Caused by Internal Iliac Vein Thrombosis With Free-Floating Thrombus Formation in the Inferior Vena Cava

Nowadays, compression ultrasonography (CUS) is the gold standard for the routine diagnosis of deep venous thrombosis (DVT). The drawback of CUS is the low sensitivity concerning the diagnosis of isolated pelvic vein thrombosis, especially referring to isolated internal iliac vein and ovarian vein thromboses. Therefore, magnetic resonance (MR) venography has become a valuable alternative. We present the case of a 45-year-old female patient with a massive pulmonary embolism with the indication for thrombolytic therapy due to severe right ventricular overload. We were not able to detect a DVT in the lower limbs of this patient with CUS. However, further DVT workup by MR venography showed a free-floating thrombus formation originating from the right internal iliac veins into the inferior vena cava. Owing to the fact that this thrombus was free floating, surgical removal of the thrombus was scheduled and performed successfully. In some patients it might be important to look for so-called rare causes of pulmonary embolism, even when CUS of the lower limbs does not reveal any DVTs. The diagnostic procedure of choice for these patients seems to be MR phlebography, as iliac and pelvic veins can be evaluated without radiation exposure with this procedure.

A case of a free-floating ball thrombus in the left atrium after administration of streptokinase in a patient with early mitral valve replacement

A case of a free-floating ball thrombus in the left atrium after administration of streptokinase in a patient with early mitral valve replacement

Free-Floating Right Ventricular Thrombus as Assessed by Real-time 3-Dimensional Transesophageal Echocardiography

A 71-year-old woman being treated with predonine at a dose of 10 mg/d for rheumatoid arthritis had a short episode of syncope lasting a couple of minutes. Her physical examination on admission revealed clear consciousness, resting tachycardia of 96 beats per minute, blood pressure of 114/68 mm Hg, jugular venous distention, and edema of the dorsum of the right foot. Electrocardiography revealed sinus tachycardia and right axis deviation. Chest radiography showed no pulmonary congestion. Transthoracic echocardiography showed a moderately dilated right ventricle with impaired right ventricular systolic function containing a large freefloating echogenic mass. There was moderate tricuspid regurgitation with an estimated pulmonary artery pressure of 59/24 mm Hg. Subsequent investigation by real-time 3-dimensional transesophageal echocardiography revealed that the large floating right intraventricular mass was highly mobile (Figure 1A and Video 1) and attached to the chordal structures of the tricuspid valve, which was prolapsing through the pulmonary valve into the main pulmonary artery. The clinical suspicion of pulmonary thromboembolism was subsequently confirmed by lung perfusion scanning. Anticoagulation therapy with intravenous heparin was initiated, and urgent cardiac surgery was performed with complete removal of the thrombus (Figure 1B). Histopathologic examination of the removed material showed findings consistent with a thrombus. Long-term oral anticoagula-

A pinball game in the left atrium

In January, 2011, a 64-year-old woman presented to us with atwo-week history of fatigue, dizziness, dyspnea on exertion, andpain in the fourth and fifth toes of her left foot. One year before, shewas diagnosed with atrial fibrillation and moderate rheumaticmitral valve stenosis. On that occasion, a transesophagealechocardiography showed a mural thrombus stuck to the posteriorwall of the left atrium, whose diameters were 3×5 cm. Therefore,anticoagulation with warfarinwas begun. A follow-up echocardiogra-phy documented the persistence of the thrombus five months beforepresentation, despite regular anticoagulation. Her thrombophiliawork-up was negative. On physical examination there was inceptivegangreneof the fingertipof the fourthtoe of her left foot. She had pal-pable bilateral femoral, popliteal, and posterior tibial pulse and a re-duced dorsalis pedis pulse. Heart auscultation was notable for aloud first heart sound, an opening snap, and a mid-diastolic murmur.The murmur changed in intensity randomly, independently by posi-tion of the patient or inspiration. Chest radiographyrevealeda dilatedleft atrium, pulmonary venous congestion, and enlarged pulmonaryartery.ECG showed atrialfibrillation. Transthoracic echocardiographyrevealed a large highly mobile mass in the left atrium. Transoesopha-geal echocardiography showed a round floating mass in the left atrialchamber,withoutevidenceof anyattachment. (Fig.1, Videos1and 2)The mass measured 2.8×2.1 cm and occasionally obstructed the mi-tral valve orifice during diastole without passing through. In systolethe mass was pushed back in the left atrium by the mitral leaflets,thus mimicking a pinball game. There was no more evidence of thevoluminous mural thrombus documented five months before. Theanticoagulation was suspended and surgery was planned. Threedays after the patient underwent cardiac surgery for removal of atrialmass and mitral valve replacement. Exploration of the left atriumrevealed a spherical, smooth, non-pedunculated thrombus free inthe atrial cavity (Fig. 2). The mitral valve was replaced using a St.Jude Medical mechanical heart valve. Amputation of affected toeswas performed concurrently. Her postoperative course was unevent-ful. Histology confirmed that the floating mass was a thrombus, cov-ered by endothelial cells.Atrial free-floating ball thrombus wasfirst described by Woodin 1814 during an autopsy of a 15-year-old girl with mitral steno-sis [1]. Free-floating thrombi are a rare condition occurring nearlyalways in the left atrium in patients with mitral stenosis, particu-larly when atrialfibrillation is present. While patients with non-valvular atrial fibrillation usually develop thrombosis of leftappendage, thrombus located in the body of the left atrium is com-moninpatientswithmitralstenosis[2]. The existence of a muralthrombus is crucial for the formation of a free-floating thrombus.In our case, we documented a pre-existing large left atrial muralthrombus few months before the presentation. This evidencestrongly suggests that it dropped off spontaneously in the atrium,maybe facilitated by anticoagulation. In fact, the thrombus wascovered by endothelium, thus suggesting it was probably old andmore resistant to dissolution. Symptoms include heart failure andsyncope for intermittent obstruction of mitral valve and systemicembolism for fragmentation. Sudden death due to incarcerationof the thrombus into the mitral orifice has been described [3].Our patient presented with dyspnea on exertion, which couldnot be explained by the moderate valve disease, and initial gan-grene of the left toes, suggesting embolization. It is likely thatsymptoms started with detachment of thrombus from the atrialwall. Although current guidelines recommend anticoagulation inpatients with atrial thrombus and mitral stenosis[4],inthispartic-ular scenario anticoagulation may not be useful and may be poten-tially harmful. Surgery is the treatment of choice since it permitsthe removal of the mass and the treatment of underling valvedisease.Supplementary materials related to this article can be foundonline at doi:10.1016/j.ijcard.2011.12.002.

Asymptomatic free-floating thrombus of the internal carotid artery

Abstract Free-floating thrombus (FFT) of the internal carotid artery, which is almost always symptomatic and is usually discovered by ultrasound or angiography performed after a transient cerebrovascular event, is a highly uncommon diagnosis. Here, we report a case of an asymptomatic freefloating internal carotid artery thrombus most probably caused by an atherosclerotic plaque rupture. It was detected by carotid ultrasound and was treated with eversion endarterectomy without any neurologic complications. Six weeks after surgery, the patient is doing well.

Transient floating thrombus of the internal carotid artery associated with the JAK2V617F mutation

Essential thrombocythemia (ET) is a myeloproliferative disorder (MPD) characterized by sustained elevated platelets. Cerebrovascular disorders can be a complication of ET, with thromboses of cerebral veins occurring more frequent than those of arteries [1, 2]. We describe a 33-year-old woman with no cardiovascular risk factors who experienced an acute ischemic stroke in the left middle cerebral artery territory (MCA). The carotid duplex on admission showed a free-floating thrombus (FFT) in the left internal carotid artery (Fig. 1a, b) that was not producing flow aceleration. However, the thrombus disappeared 2 h later without any clinical deterioration, as shown by a second carotid duplex. The arteriography confirmed these results (Fig. 1c). A brain infarction in the left MCA territory was observed on MRI (Fig. 1d). Peripheral blood showed a platelet count of 505 9 10/L. Additional studies, including an extensive battery of tests for coagulopaties and a complete cardiology study, were negative. The JAK2 mutation was detected in peripheral blood samples by a multiple allelespecific PCR (MAS-PCR). The thrombocytosis decreased spontaneously, as the platelet count dropped from 487 9 10/L at 3 months to 452 9 10/L after 6 months. Bone marrow aspiration showed clustered hyperlobulated megakaryocytes. She was diagnosed with MPD and specifically ET. Antiplatelet treatment was initiated as secondary stroke prevention. The patient presented a good outcome, with progressive neurological improvement. The presence of a mobile FFT in the internal carotid artery as cause of brain ischemia is infrequent and its prevalence and natural history are not well understood. The main associated pathologies are hypercoagulability, carotid dissections, trauma and plaque, although in many cases the association is not identified [3]. Philadelphia-negative MPD, especially ET and polycythemia vera (PV) may be associated with thrombi development, although they are produced more frequently in veins than in arteries [1, 2]. Recent diagnostic criteria for ET have lowered the platelet threshold from 600 9 10/L to 450 9 10/L [4]. Therefore, since the platelet count is not always highly elevated at the time of stroke, the diagnosis of ET is difficult. In our case, a complicated carotid thrombus was the initial presentation of an ET even in presence of mild thrombocythemia. The acquired Janus kinase 2 V617F mutation (JAK2) was recently identified in patients with MPDs [5]. This mutation has been found in more than 90% of patients with PV and in approximately 50% of those with ET, which led to a recent update of the diagnostic algorithms for MPDs, including the JAK2 mutation as a major criterion [4]. The risk of arterial thrombosis is significantly increased in patients with MPDs and the JAK2 mutation (OR 2.49, 95% CI 1.71–3.61) [1] independently of the V617F allele burden [6]. To the best of our knowledge, the presence of mobile floating thrombi in the extracranial carotid arteries associated with the presence of P. Martinez-Sanchez (&) R. Cazorla-Garcia J. Medina-Baez B. Fuentes E. Diez-Tejedor (&) Department of Neurology and Stroke Center, IdiPAZ Research Institute, La Paz University Hospital, Autonoma University of Madrid, Paseo de la Castellana 261, 28046 Madrid, Spain e-mail: patrindalo@hotmail.com

Free-floating thrombus of the carotid artery with a homozygous methylenetetrahydrofolate reductase gene mutation: a case report

Free-floating thrombus (FFT) of the carotid artery is a rare condition of currently unknown etiology. We describe a symptomatic patient with an FFT in the left common carotid artery. A duplex ultrasonography scan showed the presence of a mobile floating thrombus moving in cyclical motion with the cardiac cycles in the left common carotid artery. During emergency surgery, an FFT was seen at this location and removed. No underlying wall defect was seen at the time of surgery. In a genetic screening test, TT homozygous for the methylenetetrahydrofolate reductase (MTHFR) C677T genetic polymorphisms was detected. The patient recovered uneventfully, with no neurogical events. Lifelong anticoagulant therapy was recommended. An aggressive surgical approach is recommended in the patient to prevent embolic episodes.

Uneventful Disappearance of a Large Left Atrial Ball Thrombus with Enoxaparin in a Patient with Mitral Stenosis Associated with Pregnancy

An atrial thrombus is a relatively common echocardiographic finding in patients with mitral valve stenosis (MVS) and atrial fibrillation (AF). However, a “ball thrombus” or floating thrombus in the left atrium is a rare and specific entity associated with MVS. A 24-year-old woman with rheumatic MVS presented with complaints of progressive dyspnea and inferior limbs edema that began 23 days earlier after a caesarean operation for stillbirth carried out at 8 months of pregnancy. At the time of hospitalization, she was in New York Heart Association functional class III and the ECG showed sinus rhythm. Transthoracic color-flow Doppler echocardiography revealed a thick, stenotic mitral valve with a valvular area of 0.9 cm2, and an echogenic large left-atrial mass diagnosed as a free-floating left-atrial thrombus that was corroborated by transesophageal echocardiography. She refused surgery and was treated medically, and low molecular weight heparin (LMWH) (enoxaparin 80 mg/12 h) was given for 14 days and was discharged uneventfully on coumarin. Two days before discharge, a transthoracic and transesophageal ecocardiography showed disappearance of the ball thrombus uneventfully leaving spontaneous echo contrast inside the left atrium. To the best of our knowledge, this is the first case showing disappearance of a giant left atrial ball thrombus with LMWH treatment in a patient with severe MVS during sinus rhythm associated with pregnancy.

A free-floating left atrial thrombus develops intermittent entrapment in the mid-ventricle during diastole

Free-floating left atrial thrombi are rare. Here we report a case of a 75-year-old woman with atrial fibrillation who was admitted for treatment of acute myocardial infarction. A free-floating left atrial thrombus was found incidentally on echocardiography. Ten days after percutaneous coronary intervention, the patient had mild faintness with transient hypotension, and it was found that the left atrial thrombus had developed intermittent entrapment in the mid-ventricle during diastole, with abrupt rebound back to the left atrial cavity during systole. Urgent removal of the thrombus was performed successfully. Although the free-floating thrombus had appeared to be spherical, like a ball thrombus, on echocardiography, the excised thrombus was pedunculated. A cut section revealed a laminated thrombus with an onion-skin-like appearance.

A big floating thrombus in the common carotid artery

The management of the free-floating thrombus (FFT) is difficult, and it is unclear whether surgical or medical treatment is superior. The common carotid artery is rarely involved. An 80-year-old woman presented with right hand weakness and syncope. Ultrasound showed the presence of FFT in the left common carotid artery. A carotid endarterectomy with Dacron patch angioplasty was immediately performed without complications. In the presence of symptoms, the interventional management of FFT is advised.

80-Year-Old Man With Massive Leg Swelling

80-Year-Old Man With Massive Leg Swelling

Right atrial thrombus migrating to the superior vena cava during surgery

Free-floating right heart thrombi are extremely mobile structures that carry a very high mortality rate. We describe a case of pulmonary embolism with a free-floating right heart thrombus that migrated to the superior vena cava during the institution of cardiopulmonary bypass.