A pinball game in the left atrium

Left atrial ball thrombus after edge-to-edge mitral valve repair

A thrombus can develop in the left atrium during atrial fibrillation because the loss of contractile function leads to blood flow stasis. Anticoagulation therapy is indicated for prevention of systemic embolism, usually maintaining an international normalized ratio between 2 and 3. Rarely a massive thrombosis develops in the atrium resulting in a peduncolated ball valve thrombus or in a free-floating thrombus. These two conditions are characterized by variables in the physical findings. Such masses are hazardous and upon discovery surgical treatment, often in emergency, is mandatory. We present here the case of a patient who developed an unnoticed huge left atrial ball thrombus despite warfarin therapy after previous mitral valve surgery. <Learning objective: Risk of atrial thrombosis threatens patients suffering from atrial fibrillation. The presence of a ring and a modified valve anatomy following a surgical repair could represent an additional drive in the thrombus formation pathway. A free-floating ball thrombus in the left atrium is an unusual occurrence that may cause fatal systemic emboli or left ventricular inflow obstruction, often resulting in sudden death. In such cases, even in the absence of symptoms, prompt surgical excision is recommended.>.