Watch out for left atrial roof thrombus
The present case has been published in the journal Annals of Cardiac Anaesthesia.

A 35-year-old female presented with NYHA Grade 2/3 dyspnea and palpitations with an increase in severity for 1 month. After evaluation, she was diagnosed with severe rheumatic mitral stenosis (MS) (mitral valve area 0.9 cm2) with a giant left atrium (LA) (70 cm × 82 cm) and moderate pulmonary hypertension (pulmonary artery systolic pressure 40 mmHg).

However, no LA thrombus was appreciated during preoperative transthoracic echocardiography (TTE) study. The patient was in atrial fibrillation (AF) and had unfavorable valve anatomy for balloon mitral valvuloplasty. She was posted for elective mitral valve replacement surgery.

During an intraoperative transesophageal echocardiography (TEE), unexpectedly, a large thrombus was seen in the roof of the LA extending onto the interatrial septum (IAS) without involving the left atrial appendage (LAA) [Figure 1]. This finding was confirmed surgically after opening the LA.

The size and organized nature of the thrombus in the presence of severe MS prevented embolization into the systemic circulation. This clot was missed by the initial preoperative TTE partly due to poor acoustic windows, the unusual location, and probable initial small size.

Surgery was uneventful with complete thrombus removal and implantation of a St. Jude 25 mm mechanical mitral valve prosthesis. The patient recovered well without any neurologic dysfunction in the postoperative period.

Major takeaway:-
Patients with MS are at increased risk of thrombus formation anywhere within the LA irrespective of the cardiac rhythm. Accordingly, screening of the entire LA during intraoperative TEE is of paramount importance.

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Dr. N●●●v P●●●●●l
Dr. N●●●v P●●●●●l Cardiothoracic and Vascular Surgery
Any intervention done for giant lt atrium with af. surgical procedures like maze and plication of lt atrium can be useful for future prevention of lt ariual thrombus.
Dec 21, 2018Like