MASS THROMBUS OF THE LEFT AURICLE

Intracardiac thrombi: frequency, location, etiology, and complications: a morphologic review--Part IV

Intracardiac thrombus may develop as a consequence of multiple underlying cardiac disorders. Valvular heart disease, in particular, rheumatic mitral stenosis is frequently associated with intracardiac thrombus. Part IV of this 5-part article on intracardiac thrombus focuses on the frequency and consequences of thrombus in valvular heart disease.

Left atrial ball thrombus: review of clinical and echocardiographic manifestations with suggestions for management

Left atrial ball thrombus is an infrequent clinical syndrome, which can have a catastrophic outcome but can be readily treated when recognized. It is usually a complication of long-standing rheumatic mitral stenosis. Symptomatic presentation is variable: fragmentation of the thrombus followed by peripheral embolization will produce ischemia or infarction of myocardium, brain, viscera, or extremities; random, intermittent, partial, or total occlusion of the mitral valve orifice may cause syncope, pulmonary congestion, and occasionally sudden death in other patients. Embolic and obstructive phenomena may also occur together. Cardiac physical findings usually suggest mitral stenosis; variability in the intensity of the diastolic rumble is common. Two-dimensional echocardiography is the gold standard for identifying ball thrombus. Cardiac catheterization provides assessment of coronary artery status when needed. The outcome of untreated ball thrombus is unlikely to be favorable. The results of anticoagulation and thrombolysis are unpredictable and potentially as harmful as no treatment at all. Current evidence although scant suggests that prompt surgical removal of the free thrombus, often in conjunction with mitral valve repair or replacement, is the appropriate therapeutic course in most patients.

Left atrial ball valve thrombus. Treatable cause of clinical deterioration in a patient with mitral stenosis

A 74 year old woman with mixed mitral valve disease presented with episodes of loss of consciousness and fainting. The attacks were noted to be closely related to posture, especially crouching, and this, with the clinical finding that the radial pulse disappeared before she lost consciousness, suggested the diagnosis of a ball valve thrombus. Cardiac catheterisation confirmed the diagnosis but was followed by a fall in blood pressure necessitating emergency surgery. The only position in which the circulation could be maintained was the right lateral, with steep head down tilt, and left femoro-femoral cardiopulmonary bypass had to be established in this position. Operation confirmed the presence of a ball valve thrombus and the patient recovered uneventfully.

Comparative pathophysiological effects of methoxamine on arteriosclerotic vs. non-arteriosclerotic rats

Methoxamine, a pure alpha-adrenergic stimulating agent, has little cardiac stimulating capacity but is a very potent vasoconstrictor. Currently, its clinical use is limited to correction of hypotensive crises during anaesthesia and surgical shock. A single injection of methoxamine will produce hypertension and marked medial arterial necrosis in animals. In this connection, we subjected arteriosclerotic and non-arteriosclerotic animals to a single injection of methoxamine and sacrificed the animals 4 hours, 2, 5 and 7 days later in order to determine whether the arteriosclerotic animals would differ from the non-arteriosclerotic animals in their response to the medial necrosis inducing effects of methoxamine. Within minutes after injection, the animals became prostrate, developed congestive heart failure and mortality was high. Myocardial infarction, adrenocortical haemorrhage and thymic, involution, intestinal gangrene as well as splenic, renal and testicular thrombosis and infarction were prevalent. Serum CPK, SGOT, glucose, triglyceride, free fatty acids, cholesterol, BUN and corticosterone manifested dynamic increases but the pattern of response was quite different in the arteriosclerotic vs. non-arteriosclerotic animals. Although extensive medial necrosis was produced in the medium-sized arteries of animals with previously normal arteries, the damage was promptly repaired; the animals with pre-existing arteriosclerosis were not affected by the pressor effects of methoxamine. The induction of myocardial infarction, and extensive thrombosis and infarction are ascribed to the bradycardia-inducing effects of methoxamine and the medial necrosis-inducing effects are ascribed to its intense vasopressor activity.

Coronary embolism in rheumatic heart disease

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Mass thrombus of the left auricle

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Occlusive auricular thrombi

The literature on occlusive thrombi of the auricles has been reviewed in order to identify the symptom complex attributed to this condition. The clinicopathological findings are presented in four new cases which fit this symptom complex. Two cases are notable in that one is that of a ball thrombus occurring in the absence of mitral stenosis and another the first reported case of pedunculated thrombus of the right auricle.