Left atrial encapsulated thrombus in a non-coagulated patient with severe mitral stenosis

Abstract

Background. Rheumatic mitral stenosis (MS) is associated with left atrium (LA) thrombus in patients in sinus rhythm (3 % – 13 %) and markedly increases in atrial fibrillation (~33 %).The presence of LA thrombus carries a risk of systemic embolization and neurologic morbidity. The discovery of a massive thrombus through echocardiography obliges the clinicians to strategies for secondary prevention of trombembolic events. The main line of actions of stroke prevention in cardioembolism is mostly connected with antithrombotic drugs, but also other, more invasive. Certainly, surgery is the best solution for a successful prognostic. Case report. We present a case of a non-anticoagulated 56-year-old woman with severe MS. She was admitte to cardiology department with dyspnea, palpitations and fatigue. Anamnesis: 10 years of atrial fibrillation (AF) and 7 years with arterial hypertension. Physical examination revealed an irregular pulse, at a rate of 76 beats/min. The ECG revealed an atrial fibrillation with a rate 75-100 b/min. ECHOCG - revealed a severe MS (V max 2.9 m/s, GP max – 33.8 mm/hg, area – 0.5 cm2) with third degree mitral regurgitation and LA thrombus (90*80 mm), fixed to the upper and rear wall of the LA, third-degree tricuspid regurgitation. Left atrium was enlarged (59 mm), severe pulmonary arterial hypertension. The preoperative coronarography showed the absence of any sign of atherosclerosis. The patient was referre to cardiac surgery for correction of valvular pathology. Cardio-surgical intervention was performe: mechanical MV prosthesis ST – JUDE MED 27, DEVEGA-CABROL tricuspid annuloplasty, removing the massive encapsulated thrombus (90*80 mm) from the LA with the origin into the left appendage, obliterating the pulmonary veins, then - surgical closure of the left atrial appendage. After surgery, the patient had recovered well without any neurologic dysfunction in the postoperative period. Conclusions. The risk of cardioembolic complication to the patient with severe mitral valve stenosis is very high and depends on age and the presence of other comorbidities. Anticoagulant treatment in patients with severe MS and AF is paramount, cessation of anticoagulant treatment leads to serious complications such as stroke. In our case, the size and organized nature of the thrombus, prevented embolization into the systemic circulation, but in other cases the risk is very high. In the era of open-heart surgery and of mitral valve replacement, the prognosis for most patients with valvulopathies, especially those with rheumatic etiology is excellent.