CASE REPORTS

Syncope with a Twist

Sucheta Gosavi, MD, Azamuddin Khaja, MD, and Kul Aggarwal, MD, Columbia, Missouri

Left atrial ball thrombus is an uncommon entity,seen more commonly in the presence of mitral

valve disease. We present here a case of a large left

doi:10.1016/j.echo.2006.08.017

atrial thrombus presenting as sudden cardiacdeath. (J Am Soc Echocardiogr 2006;19:1529.e1-e3.)

Left atrial (LA) masses are usually caused by cardiacthrombi, vegetations, tumors, and, rarely, normalanatomic variants. Most commonly, LA thrombusoriginates from the LA appendage and infrequentlygets infected, causing systemic embolization. Wedescribe here an interesting case of sudden cardiacdeath related to a large LA thrombus.

CASE REPORT

A 75-year-old white woman presented to our facilitywith history of sudden collapse at home. She was foundto be in asystole and advanced cardiac life support wasperformed at home before the transfer. On admission,she was unconscious, in atrial fibrillation with a systolicblood pressure of 70 mm Hg, and requiring ventilatorysupport.

Past history was significant for hypertension, parox-ysmal atrial fibrillation, presyncope, and syncope. Thepatient was not taking any anticoagulants except aspi-rin.

Echocardiographic Findings

Transthoracic echocardiography showed a sphericaldensity in the left atrium measuring 2 cm in diameter(Figure 1). LA was moderately dilated. Mitral valveleaflet tips were mildly thickened with restricted open-ing. There was mild mitral regurgitation. Transesopha-geal echocardiography confirmed the findings from thetransthoracic echocardiogram and showed a large LAthrombus measuring 50 � 18 mm, arising from the LAappendage and prolapsing across the mitral valve (Fig-ures 2, 3, and video clips 1-4). Doppler showed a meangradient of 9 mm Hg across the mitral valve with apressure half-time of 136 milliseconds and a calculated

From the Department of Internal Medicine (S.G.), and Division ofCardiology, Department of Internal Medicine, University of Mis-souri-Columbia.Reprint requests: Sucheta Gosavi, MD, 1700 Forum Blvd, Apart-ment 2006, Columbia, MO 65203 (E-mail: gosavisucheta@hotmail.com).0894-7317/$32.00Copyright 2006 by the American Society of Echocardiography.

mitral valve area of 1.69 cm2, consistent with mildmitral stenosis (MS). Estimated pulmonary artery sys-tolic pressure was elevated at 45 mm Hg, which wasmuch higher considering that she had mild MS (Figure4).

Unfortunately the patient had sustained severe anoxicbrain injury, and the family requested withdrawal of care.

Figure 1 Mass seen in the left atrium on transthoracicechocardiogram.

Figure 2 Pedunculated thrombus arising from the leftatrial appendage.

Permission for an autopsy was not granted.

1529.e1

Journal of the American Society of Echocardiography1529.e2 Gosavi, Khaja, Aggarwal December 2006

DISCUSSION

LA ball thrombus was initially identified in 1814 byWood1 and a subsequent report of this in nonrheu-matic atrial fibrillation was in 1992.2 The first de-scribed case of an infected LA thrombus was in2000.3 The peak age incidence of a LA thrombus hasbeen reported as the fifth decade with a femalepreponderance of 3:1.4

Pathogenesis

The thrombus usually forms in the presence of atrialfibrillation, valvular heart disease (MS), or myocar-dial infarction, although a few cases caused byextracardiac carcinoma or viral myocarditis havebeen reported in the literature.5 Recent advances in

Figure 3 Ball-valve thrombus prolapsing across the mitralvalve.

Figure 4 Mitral Dopp

technology and widespread use of echocardiogra-phy, cardiac computed tomography, and cardiacmagnetic resonance imaging have led to betterrecognition of this entity.

The majority of the LA free-floating thrombi areseen with MS and atrial fibrillation, although they arenot absolute prerequisites. They can occur as acomplication of infective endocarditis, causing sys-temic emboli, cerebrovascular accidents, syncope,and sudden cardiac death.4,6

It is hypothesized that the ball valve thrombus isinitially formed in the LA appendage, extending intothe left atrium. Subsequently, this spherical-shapedthrombus may get disconnected from the LA walland can spin at a random speed in a clockwisedirection.7 In systole it is propelled backwards intothe left atrium by the anterior mitral leaflet causingintermittent ping-pong acceleration.6

In our patient the pedicle was present and thethrombus was prolapsing across the mitral orificeinto the left ventricle (Figure 3), causing dynamicocclusion of the ventricular inflow. The patient alsohad urosepsis causing increased cardiac output thatled to increased mitral filling and sudden prolapse ofthe thrombus at the mitral orifice causing suddencardiac arrest because of complete cessation ofblood flow across the mitral orifice. This mechanismhas been well documented in the literature espe-cially in the presence of MS.6-8 Schecter et al9

reported sudden cardiac death in 5% of patients witha LA thrombus.

Management

Anticoagulant and thrombolytic therapy do notappear to have any role in the acute management

ler flow pattern.

Journal of the American Society of EchocardiographyVolume 19 Number 12 Gosavi, Khaja, Aggarwal 1529.e3

of LA ball thrombus.3,7,10 Thrombolysis is not indi-cated for LA masses because of the risk of emboli-zation. Nurra et al11 reported successful treatment ofa free-floating LA thrombus with an oral anticoagu-lant, which could be the treatment of choice inhigh-risk surgical candidates or when an operation isrefused by the patient. There are, however, noreports of successful treatment with heparin.3,6 Ourpatient had a history of paroxysmal atrial fibrillationbut was not on anticoagulation, which could haveprevented this adverse outcome. In suitable pa-tients, immediate cardiac operation is the treatmentof choice but our patient already had evidence ofsevere anoxic brain injury and the family had de-cided on conservative medical treatment.

Conclusion

In addition to the impressive pictures, this casedemonstrates the importance of recognizing thisnot-so common condition early in people presentingwith syncope and sudden cardiac death. It alsoreiterates the beneficial effects of anticoagulation inpatients with atrial fibrillation to avoid such futurecatastrophes.

REFERENCES

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3. Okayama H, Kawasaki S, Takagaki Y, Kawada H, SumimotoT, Hirayama T. Infection of left atrial thrombus associatedwith mitral stenosis. Chest 2000;117:1201-3.

4. Lie JT, Entman ML. ‘Hole-in-one’ sudden death: mitralstenosis and left atrial ball thrombus. Am Heart J 1976;91:798-804.

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9. Schecter DC. Left atrial ball-valve thrombus. N Y State J Med1982;82:1831-8.

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