Case Reports Cardiology 61: 298-302 (1976)
Massive Left Atrial Thrombus: A Case Report F ranklin B. Saksena, G eorge K roll and A rthur
de
Boer
Heart Station, VA Research Hospital, Chicago, and Department of Cardiac Surgery, Wesley Memorial Hospital, Chicago, III.
Key Words: Atrial thrombus • Reversed mitral gradient Abstract. This case report describes a patient with aortic and mitral valvular disease who had a massive left atrial thrombus. The left atrial thrombus produced a disappearance of signs of mitral stenosis and a reversed pan diastolic mitral valve gradient. This gradient occurred in the absence of any diastolic mitral insufficiency and may have been due to artifactual lowering of the left atrial pressure by an organized left atrial clot.
Introduction Massive left atrial thrombus (MLAT) is usually associated with mitral stenosis, occurring in 2-10% of cases [3, 6, 7], This report concerns a patient who had a MLAT associated with a spurious reversed gradient across the mitral valve in the absence of any diastolic mitral insufficiency. The clinical features and diagnosis of MLAT are also discussed.
A 44-year-old man was admitted in 1960 to VA Research Hospital complaining of dyspnea and edema. He had been hospitalized 1 year previously with similar complaints, at which time right heart catheterization had revealed mild pulmonary hypertension (table I). There was no history of acute rheumatic fever or chorea. Physical examination revealed a blood pressure of 140/94. He had a diffuse heaving apical impulse 3 cm to the left of the midclavicular line. The first heart sound was accentuated. The presence of a faint opening snap occurring 0.06 sec after A, was confirmed by phonocardiography. A grade 1/6 systolic murmur and a grade 2/6 mid-diastolic rumbling murmur were heard at the apex. In addition, there was a
Downloaded by: King's College London 137.73.144.138 - 7/15/2018 10:55:12 PM
Case Report
299
Sa k s e n a /K r o l l /de B oer
Table I. Cardiac catheterization data Site
Pressure, mm Hg
Right atrium Right ventricle Pulmonary artery I.eft atrium Left ventricle Aorta Cardiac output, l/min Mitral valve area, cm-
1959
I960
1971
(7) 42/5 40/20 (26)
(4) 30/4 30/12(19) (17) 105/3 85/50
(2) 24/2 24/15 (18) (9) 165/16 114/63
4.00 1.6
3.33 -
-
114/70 (brachial)
grade 3/6 early diastolic decrescendo murmur heard along the left sternal border as well as a grade 3/6 aortic ejection systolic murmur. An electrocardiogram showed right axis deviation and atrial fibrillation with rapid ventricular response. The patient responded well to therapy with digoxin and hydrochlorthiazide. Conversion to sinus rhythm was accomplished with quinidine. Cardiac catheterization (table I) showed normal right heart pressures and a high left atrial pressure. Significant gradients were noted across the mitral and aortic valves. Calcification of the mitral valve was seen on fluoroscopy. No angiograms were performed. The patient was lost to follow-up from 1962 to 1970, but apparently did well and continued working as a cement finisher. He continued taking digoxin and prophylactic penicillin during this time. From December. 1970 to August. 1971 the patient had only exertional dyspnea on walking two blocks or up two flights of stairs. Physical examination in August, 1971 was essentially unchanged from I960 except that the opening snap and mitral diastolic murmur were no longer audible and that the murmurs of aortic insufficiency and stenosis had become louder. Chest roentgenogram demonstrated marked enlarge ment of the left atrium and moderate left ventricular enlargement. Repeat cardiac catheterization (table I) showed normal right heart pressures. No wedge pressure was obtained but its value must be assumed to be at least 15 (= PA diastolic pressure). There was moderate aortic stenosis. Severe aortic insufficiency was seen on aortic root angiography. Pulmonary angiography was not done. The left atrium was entered without difficulty using a Brockenbrough transseptal catheter. The location of this catheter was confirmed by obtained a blood sample showing 92% oxygen saturation, and an atrial pressure tracing showing c and v waves that differed in contour from the right atrial pressure tracing. Simultaneous left ventricular and left atrial pressures showed a reversed holo-diastolic gradient across
Downloaded by: King's College London 137.73.144.138 - 7/15/2018 10:55:12 PM
Values in parentheses indicate mean pressures.
300
Sa k s e n a ; K r o i -L/d e Boer
Fig. I. Simultaneous left ventricular and left atrial pressure tracings. There is a reversed pan-diastolic gradient across the mitral valve. the mitral valve (fig. 1). Pressures were measured with the zero reference 10 cm from the back. The reversed diastolic gradient persisted unchanged even when the left atrial catheter was judiciously flushed with heparinized solution, the Statham pressure gauges were reversed and the catheter manipulated in differing LA sites. Mitral in sufficiency could not be demonstrated either by LV to LA dye curves or by LV angiography. The left atrium could not be entered retrogradely from the left ventricle with a Shirey catheter and the Brockenbrough catheter could not be advanced from the left atrium to left ventricle. The patient underwent surgical replacement of his mitral and aortic valves in September, 1971. The left atrium was markedly enlarged and almost completely filled with about 300-400 cm* of organized thrombus. The mitral valve was calcified and stenotic (estimated area = 1.5 cm2). Mild mitral regurgitation was also noted. Aortic stenosis and insufficiency were also confirmed. The patient had considerable sympto matic improvement following operation and has been free of recurrent heart failure for the past 4 years.
Our patient had several features that are associated with MLAT: cal cified mitral valve, atrial fibrillation [5, 8, 17] and the subsequent dis appearance of the opening snap and the murmur of mitral stenosis [17]. Pulmonary hypertension is usually seen in MLAT [5] but for unknown reasons, resting PA pressures were normal in our patient. Calcification in the LA cavity is highly suggestive of MLAT but it is a rare finding [3, 9], it was absent in our patient. Echocardiography may be helpful in detecting a large left atrial clot, prior to cardiac catheterization [4, 16]. F eigenbaum [4] reported that there
Downloaded by: King's College London 137.73.144.138 - 7/15/2018 10:55:12 PM
Discussion
Massive Left Atrial Thrombus: A Case Report
301
may be several linear echoes running through the left atrial cavity but that these need to be distinguished from normal posterior atrial wall echoes. Echocardiography was not performed in our patient. Left atrial thrombi have been diagnosed by opacification of the left atrium via pulmonary artery or left atrial angiography [10, 14, 15]. If a left atrial clot is suspected, then transseptal catheterization and left atrial angiography should be avoided because of the risk of thromboembolism from both of these procedures [2, 10, 14]. Since thromboembolism has not been reported after pulmonary angiography [14, 15] in mitral stenosis, the latter method is preferred in delineating left atrial thrombus. Our patient had a reversed pan-diastolic gradient across the mitral valve, an event that is physiologically impossible. Severe aortic insuffi ciency or artifactural lowering of the left atrial pressure might partially explain the finding. Severe aortic insufficiency would be unlikely to fully account for this reversed mitral gradient, because in our patient the re versed gradient was pan-diastolic and not end-diastolic [11, 13, 18] and there was no diastolic mitral regurgitation [1], Spurious lowering of the left atrial pressure may occur [12] if the Brockenbrough catheter had per forated the left atrium and recorded pressure in both the left atrium as well as in the pericardial sac. However, in our patient there is no evidence that the left atrium was perforated at the time of cardiac catheterization. Another possibility is that an organized left atrial clot may not adequately transmit the left atrial pressure via a catheter that is embedded in it. Emphasis is placed on the fact that the clot must be organized and fibrotic, as a fresh clot in an in vitro system does faithfully transmit phasic pressure [personal observations]. To the best of our knowledge, this is the first reported instance of a holodiastolic reversed mitral gradient occurring in association with MLAT. The presence of a reversed mitral holodiastolic gradient should mitigate against catheter manipulation within the left atrium because of the danger of systemic embolization and suggest the need to opacify the left atrium via pulmonary angiography to confirm MLAT.
1 A ldridge, H. E.; Lansdown, E. I., and W igle, E. D.: Diastolic mitral insuffi ciency. Circulation 33-34: suppl. III. p. 42 (1966). 2 Braunwai.d, E.: Transseptal left heart catheterization. Circulation 37-38: suppl. Ill, pp. 74-79 (1968).
Downloaded by: King's College London 137.73.144.138 - 7/15/2018 10:55:12 PM
References
302
S aksf .n a /K r o l l /d e B oer
3 Evans, W. and Benson, R.: Mass thrombus of left auricle. Br. Heart J. 10: 39-47 (1948). 4 F eigenbaum, H.: Echocardiography, p. 152 (Lea & Febiger, Philadelphia 1972). 5 P rater, R. W. M.; You, K, and J ordan, A.: Massive atrial thrombus. N.Y. St. J. Med. 73: 654-655(1973).
6 G arvin, C. F.: Ball thrombi in the heart. Am. Heart J. 21: 371-374 (1941). 7 G ubbay, E. R. and P omerantz, H. Z.\ Mass thrombus of the left auricle. Can. med. Ass. J. 84: 258-262 (1961). 8 G unton, R. W. and Manning, G. W.: Mitral occlusion due to mass thrombus of the left auricle. Can. med. Ass. J. 63: 470-472 (1950). 9 H arthorne, J. W.; Selzer, R. A., and Austen, W.G.: Calcification of left atrium: its significance, detection and proposed surgical management. Circulation 32: suppl. 2, p. 108 (1965). 10 L ewis, K. B.; C riley, J.E., and Ross, R.S.: Detection of left atrial thrombus by cineangiography. Am. Heart J. 70: 612-619 (1965). 11 Lochaya. S.; Igarashi. M., and Shaffer, A. B.: Late diastolic mitral regurgitation secondary to aortic insufficiency: its relationship to the Austin Flint murmur. Am. Heart J. 74: 161-169 (1967). 12 Morris, J. J.; T hompson, H. K.; Rackley, C, E.; Whalen, R. F.., and Mc I ntosh. H. D.: Problems and complications with the use of side-hole cardiac catheters. Am. Heart J. 71: 313-318 (1966). 13 O liver, G.C.; G azetopoulos, N., and D euciiar, D. C.: Reversed mitral diastolic gradient in aortic incompetence. Br. Heart J. 29: 239-245 (1967). 14 Parker, B. M.; F riendenberg. M. J.; T empleton, A. W., and Buford, T. H.: Preoperative angiocardiographic diagnosis of left atrial thrombi in mitral stenosis. New Engl. J. Med. 273: 136-140 (1965). 15 Sowell, B.: Left atrial thrombus. J. S. Carol, med. Ass. 66: 183-185 (1970). 16 Spangler, R. D. and O kin, J. T.: Echocardiographic demonstration of a left atrial
F. Saksf.na, MD, Chief, Cardiac Catheterization Laboratory, Cook County Hospital, Division of Adult Cardiology, 1825 W. Harrison Street, Chicago, II. 60612 (USA)
Downloaded by: King's College London 137.73.144.138 - 7/15/2018 10:55:12 PM
thrombus. Chest 67: 716-718 (1975). 17 S urawicz, B. and N ierenberg , M.A.: Association of silent mitral stenosis with massive thrombi in the left atrium. New Engl. J. Med. 263: 423-431 (1960). 18 W ong , M.: Diastolic mitral regurgitation. Hemodynamic and angiographic cor relation. Br. Heart J. 31: 468-473 (1969).
Massive Left Atrial Thrombus: A Case Report F ranklin B. Saksena, G eorge K roll and A rthur
de
Boer
Heart Station, VA Research Hospital, Chicago, and Department of Cardiac Surgery, Wesley Memorial Hospital, Chicago, III.
Key Words: Atrial thrombus • Reversed mitral gradient Abstract. This case report describes a patient with aortic and mitral valvular disease who had a massive left atrial thrombus. The left atrial thrombus produced a disappearance of signs of mitral stenosis and a reversed pan diastolic mitral valve gradient. This gradient occurred in the absence of any diastolic mitral insufficiency and may have been due to artifactual lowering of the left atrial pressure by an organized left atrial clot.
Introduction Massive left atrial thrombus (MLAT) is usually associated with mitral stenosis, occurring in 2-10% of cases [3, 6, 7], This report concerns a patient who had a MLAT associated with a spurious reversed gradient across the mitral valve in the absence of any diastolic mitral insufficiency. The clinical features and diagnosis of MLAT are also discussed.
A 44-year-old man was admitted in 1960 to VA Research Hospital complaining of dyspnea and edema. He had been hospitalized 1 year previously with similar complaints, at which time right heart catheterization had revealed mild pulmonary hypertension (table I). There was no history of acute rheumatic fever or chorea. Physical examination revealed a blood pressure of 140/94. He had a diffuse heaving apical impulse 3 cm to the left of the midclavicular line. The first heart sound was accentuated. The presence of a faint opening snap occurring 0.06 sec after A, was confirmed by phonocardiography. A grade 1/6 systolic murmur and a grade 2/6 mid-diastolic rumbling murmur were heard at the apex. In addition, there was a
Downloaded by: King's College London 137.73.144.138 - 7/15/2018 10:55:12 PM
Case Report
299
Sa k s e n a /K r o l l /de B oer
Table I. Cardiac catheterization data Site
Pressure, mm Hg
Right atrium Right ventricle Pulmonary artery I.eft atrium Left ventricle Aorta Cardiac output, l/min Mitral valve area, cm-
1959
I960
1971
(7) 42/5 40/20 (26)
(4) 30/4 30/12(19) (17) 105/3 85/50
(2) 24/2 24/15 (18) (9) 165/16 114/63
4.00 1.6
3.33 -
-
114/70 (brachial)
grade 3/6 early diastolic decrescendo murmur heard along the left sternal border as well as a grade 3/6 aortic ejection systolic murmur. An electrocardiogram showed right axis deviation and atrial fibrillation with rapid ventricular response. The patient responded well to therapy with digoxin and hydrochlorthiazide. Conversion to sinus rhythm was accomplished with quinidine. Cardiac catheterization (table I) showed normal right heart pressures and a high left atrial pressure. Significant gradients were noted across the mitral and aortic valves. Calcification of the mitral valve was seen on fluoroscopy. No angiograms were performed. The patient was lost to follow-up from 1962 to 1970, but apparently did well and continued working as a cement finisher. He continued taking digoxin and prophylactic penicillin during this time. From December. 1970 to August. 1971 the patient had only exertional dyspnea on walking two blocks or up two flights of stairs. Physical examination in August, 1971 was essentially unchanged from I960 except that the opening snap and mitral diastolic murmur were no longer audible and that the murmurs of aortic insufficiency and stenosis had become louder. Chest roentgenogram demonstrated marked enlarge ment of the left atrium and moderate left ventricular enlargement. Repeat cardiac catheterization (table I) showed normal right heart pressures. No wedge pressure was obtained but its value must be assumed to be at least 15 (= PA diastolic pressure). There was moderate aortic stenosis. Severe aortic insufficiency was seen on aortic root angiography. Pulmonary angiography was not done. The left atrium was entered without difficulty using a Brockenbrough transseptal catheter. The location of this catheter was confirmed by obtained a blood sample showing 92% oxygen saturation, and an atrial pressure tracing showing c and v waves that differed in contour from the right atrial pressure tracing. Simultaneous left ventricular and left atrial pressures showed a reversed holo-diastolic gradient across
Downloaded by: King's College London 137.73.144.138 - 7/15/2018 10:55:12 PM
Values in parentheses indicate mean pressures.
300
Sa k s e n a ; K r o i -L/d e Boer
Fig. I. Simultaneous left ventricular and left atrial pressure tracings. There is a reversed pan-diastolic gradient across the mitral valve. the mitral valve (fig. 1). Pressures were measured with the zero reference 10 cm from the back. The reversed diastolic gradient persisted unchanged even when the left atrial catheter was judiciously flushed with heparinized solution, the Statham pressure gauges were reversed and the catheter manipulated in differing LA sites. Mitral in sufficiency could not be demonstrated either by LV to LA dye curves or by LV angiography. The left atrium could not be entered retrogradely from the left ventricle with a Shirey catheter and the Brockenbrough catheter could not be advanced from the left atrium to left ventricle. The patient underwent surgical replacement of his mitral and aortic valves in September, 1971. The left atrium was markedly enlarged and almost completely filled with about 300-400 cm* of organized thrombus. The mitral valve was calcified and stenotic (estimated area = 1.5 cm2). Mild mitral regurgitation was also noted. Aortic stenosis and insufficiency were also confirmed. The patient had considerable sympto matic improvement following operation and has been free of recurrent heart failure for the past 4 years.
Our patient had several features that are associated with MLAT: cal cified mitral valve, atrial fibrillation [5, 8, 17] and the subsequent dis appearance of the opening snap and the murmur of mitral stenosis [17]. Pulmonary hypertension is usually seen in MLAT [5] but for unknown reasons, resting PA pressures were normal in our patient. Calcification in the LA cavity is highly suggestive of MLAT but it is a rare finding [3, 9], it was absent in our patient. Echocardiography may be helpful in detecting a large left atrial clot, prior to cardiac catheterization [4, 16]. F eigenbaum [4] reported that there
Downloaded by: King's College London 137.73.144.138 - 7/15/2018 10:55:12 PM
Discussion
Massive Left Atrial Thrombus: A Case Report
301
may be several linear echoes running through the left atrial cavity but that these need to be distinguished from normal posterior atrial wall echoes. Echocardiography was not performed in our patient. Left atrial thrombi have been diagnosed by opacification of the left atrium via pulmonary artery or left atrial angiography [10, 14, 15]. If a left atrial clot is suspected, then transseptal catheterization and left atrial angiography should be avoided because of the risk of thromboembolism from both of these procedures [2, 10, 14]. Since thromboembolism has not been reported after pulmonary angiography [14, 15] in mitral stenosis, the latter method is preferred in delineating left atrial thrombus. Our patient had a reversed pan-diastolic gradient across the mitral valve, an event that is physiologically impossible. Severe aortic insuffi ciency or artifactural lowering of the left atrial pressure might partially explain the finding. Severe aortic insufficiency would be unlikely to fully account for this reversed mitral gradient, because in our patient the re versed gradient was pan-diastolic and not end-diastolic [11, 13, 18] and there was no diastolic mitral regurgitation [1], Spurious lowering of the left atrial pressure may occur [12] if the Brockenbrough catheter had per forated the left atrium and recorded pressure in both the left atrium as well as in the pericardial sac. However, in our patient there is no evidence that the left atrium was perforated at the time of cardiac catheterization. Another possibility is that an organized left atrial clot may not adequately transmit the left atrial pressure via a catheter that is embedded in it. Emphasis is placed on the fact that the clot must be organized and fibrotic, as a fresh clot in an in vitro system does faithfully transmit phasic pressure [personal observations]. To the best of our knowledge, this is the first reported instance of a holodiastolic reversed mitral gradient occurring in association with MLAT. The presence of a reversed mitral holodiastolic gradient should mitigate against catheter manipulation within the left atrium because of the danger of systemic embolization and suggest the need to opacify the left atrium via pulmonary angiography to confirm MLAT.
1 A ldridge, H. E.; Lansdown, E. I., and W igle, E. D.: Diastolic mitral insuffi ciency. Circulation 33-34: suppl. III. p. 42 (1966). 2 Braunwai.d, E.: Transseptal left heart catheterization. Circulation 37-38: suppl. Ill, pp. 74-79 (1968).
Downloaded by: King's College London 137.73.144.138 - 7/15/2018 10:55:12 PM
References
302
S aksf .n a /K r o l l /d e B oer
3 Evans, W. and Benson, R.: Mass thrombus of left auricle. Br. Heart J. 10: 39-47 (1948). 4 F eigenbaum, H.: Echocardiography, p. 152 (Lea & Febiger, Philadelphia 1972). 5 P rater, R. W. M.; You, K, and J ordan, A.: Massive atrial thrombus. N.Y. St. J. Med. 73: 654-655(1973).
6 G arvin, C. F.: Ball thrombi in the heart. Am. Heart J. 21: 371-374 (1941). 7 G ubbay, E. R. and P omerantz, H. Z.\ Mass thrombus of the left auricle. Can. med. Ass. J. 84: 258-262 (1961). 8 G unton, R. W. and Manning, G. W.: Mitral occlusion due to mass thrombus of the left auricle. Can. med. Ass. J. 63: 470-472 (1950). 9 H arthorne, J. W.; Selzer, R. A., and Austen, W.G.: Calcification of left atrium: its significance, detection and proposed surgical management. Circulation 32: suppl. 2, p. 108 (1965). 10 L ewis, K. B.; C riley, J.E., and Ross, R.S.: Detection of left atrial thrombus by cineangiography. Am. Heart J. 70: 612-619 (1965). 11 Lochaya. S.; Igarashi. M., and Shaffer, A. B.: Late diastolic mitral regurgitation secondary to aortic insufficiency: its relationship to the Austin Flint murmur. Am. Heart J. 74: 161-169 (1967). 12 Morris, J. J.; T hompson, H. K.; Rackley, C, E.; Whalen, R. F.., and Mc I ntosh. H. D.: Problems and complications with the use of side-hole cardiac catheters. Am. Heart J. 71: 313-318 (1966). 13 O liver, G.C.; G azetopoulos, N., and D euciiar, D. C.: Reversed mitral diastolic gradient in aortic incompetence. Br. Heart J. 29: 239-245 (1967). 14 Parker, B. M.; F riendenberg. M. J.; T empleton, A. W., and Buford, T. H.: Preoperative angiocardiographic diagnosis of left atrial thrombi in mitral stenosis. New Engl. J. Med. 273: 136-140 (1965). 15 Sowell, B.: Left atrial thrombus. J. S. Carol, med. Ass. 66: 183-185 (1970). 16 Spangler, R. D. and O kin, J. T.: Echocardiographic demonstration of a left atrial
F. Saksf.na, MD, Chief, Cardiac Catheterization Laboratory, Cook County Hospital, Division of Adult Cardiology, 1825 W. Harrison Street, Chicago, II. 60612 (USA)
Downloaded by: King's College London 137.73.144.138 - 7/15/2018 10:55:12 PM
thrombus. Chest 67: 716-718 (1975). 17 S urawicz, B. and N ierenberg , M.A.: Association of silent mitral stenosis with massive thrombi in the left atrium. New Engl. J. Med. 263: 423-431 (1960). 18 W ong , M.: Diastolic mitral regurgitation. Hemodynamic and angiographic cor relation. Br. Heart J. 31: 468-473 (1969).
