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A free left atrial ball thrombus is relatively a rare diagnosis and usually leads to systemic embolization or fatal complication of thrombus incarceration in left ventricle inflow. We report a case of 52-year-old woman who was admitted to hospital with symptoms of heart failure. Routine echocardiography showed a free-floating ball thrombus in the left atrium. The free-floating thrombus was round with smooth surface and about 3.7 mm in diameter. The mitral valve prosthesis was well-functioning. The computed tomography of the patient also showed the left atrial ball thrombus. The erratic finding was that the patient was compliant on oral anticoagulants for the last 6 months with her INR in theraputic range. This suggested that this thrombus had been there for a some time and anticoagulants failed to resolve this problem. She was referred to cardiac surgery for thrombus extraction but the patient refused to have the operation.

A left atrial movable ball thrombus is unusual and may cause fatal systemic emboli or left ventricular inflow obstruction. Among movable ball thrombi, a spinning ball thrombus is a rare and devastating occurrence that results in cardioembolic stroke. Here, we report the case of an 88-year-old woman with a large spherical thrombus spinning in the left atrium when a catastrophic cardioembolic stroke recurred. She had a history of atrial fibrillation but was unable to continue anticoagulation therapy due to hemorrhagic complications and developed an initial cerebral embolism with a large thrombus attached to the left atrium. Twelve days after the initiation of anticoagulation therapy, an extensive cerebral embolism throughout the bilateral frontal lobe recurred with disturbance of consciousness. Transthoracic echocardiography revealed a large detached spherical thrombus spinning in the left atrium. She did not recover consciousness and was moved to another hospital for palliative care three months later. Movable type left atrial thrombi are regarded as a high risk for thromboembolic events, but those with spinning movements may have a worse prognosis.

We describe the case of a 3-year-old girl who presented with a large, mobile, ball mass in the right atrium on routine transthoracic echocardiography at one year after an intraatrial repair. Considering the risk of pulmonary embolization, emergent surgery was successfully performed to remove the mass, and histopathological examination revealed that it was a ball thrombus with a fibrin clot.

Few cases of a left atrial thrombus without mitral valve disease have been reported. We present an unusual case in which a patient presented to the emergency department with syncope and acute cerebral ischemia caused by a ball thrombus originating from the left atrium (LA). An emergency bedside echocardiogram showed the LA ball thrombus intermittently obstructing the mitral orifice and, at times, compromising the left ventricular outflow tract. This thrombus was determined to be the source of cerebral embolization resulting in acute ischemia. Surgical excision of the mass was performed. At operation, the thrombus was found to be tethered to the left atrial appendage. This tethering was not apparent on the echocardiographic images, where the thrombus appeared to be free floating. This case demonstrates the utility of transthoracic echocardiography in establishing the etiology of emergent conditions seemingly unrelated to acute cardiac disease, in this situation a neurologic presentation with syncope and cerebral ischemia.

An 87-year-old female presented altered mental status and left hemiparesis. A cerebral angiogram showed abrupt cutoff of the right internal carotid artery. Mechanical thrombectomy was performed. Postoperative transthoracic echocardiography revealed a free-floating ball thrombus (FFBT) in left atrium. Surgical removal of the thrombus was recommended, but, due to the patient's poor general health status, she was treated with anticoagulation therapy. Her clinical course was uneventful. This article is protected by copyright. All rights reserved.

An 18 year-old woman who underwent secundum atrial septal defect (ASD) closure with a dacron patch 10 months prior returned for follow-up examinations. She received no anticoagulation therapy and remained asymptomatic after surgery. The patient was in normal sinus rhythm and there was no abnormality in physical examination or coagulation testing. Transthoracic echocardiograms (TTE) showed a globular, moderate echoic, homogenous mass (2 cm 2 cm) attached to the anterolateral wall of the right atrium by a narrow stalk, moving back and forth during the cardiac cycle without changing shape or protruding into the right ventricle (Fig. 1A, Video 1). Delayed gadolinium-enhanced

In patients with mitral stenosis (MS), a free-floating ball thrombus in the left atrium (LA) is a very rare clinical manifestation, but has potentially catastrophic consequences such as fatal systemic emboli or total obstruction of the narrowed mitral valve orifice, often resulting in sudden death. In this report, we demonstrated a free-floating ball thrombus within the LA cavity and transient complete occlusion of blood flow through the stenotic mitral valve by transthoracic echocardiography. Awareness of the possibility of such an entity, early diagnosis and treatment may prevent significant morbidity and mortality.

Free-floating left atrial ball thrombus is an extremely rare and serious disorder that usually occurs in the setting of a large, dilated left atrium with stagnant flow, commonly the result of severe rheumatic mitral stenosis and accompanying atrial fibrillation. In the present case, we report a free-floating left atrial ball thrombus developed in an 11-year-old child with idiopathic restrictive cardiomyopathy during sinus rhythm and manifested as peripheral arterial embolic event. To our knowledge, this is the first case of free-floating left atrial ball thrombus developed in a patient with restrictive cardiomyopathy. Furthermore, this also is the first case of free-floating left atrial ball thrombus developed in a patient during sinus rhythm.

We describe a case of a patient with a history of chronic atrial fibrillation who presented with sudden onset of left hemiplegia. Nine months earlier the longstanding warfarin therapy had been suspended due to a hemorrhagic stroke. Transthoracic echocardiography revealed a large free-floating highly mobile mass in the left atrium and severe mitral valve regurgitation. Due to the potential risk of an embolic event or a hemodynamic collapse, a decision to carry out an emergency operation was made irrespective of the neurological condition of the patient. Unfortunately, the patient died on the 18th postoperative day after a freshly occurring hemorrhagic stroke.

巨大な球状血栓を伴った特発性右房拡張症に対する1手術例を経験した. 症例は28歳, 女性. 8年前より心拡大を指摘されていたが, 自覚症状はなかった. 肺炎で近医入院中に施行された心エコー検査で異常を指摘, 当科に紹介された. 胸部X線では右第II弓は突出し, 心エコー検査では房室弁に逆流はなく, 右房の著明な拡張とその内部に高音響性腫瘤を認めた. 手術所見では右房は拡張し, その壁はきわめて薄く, 右房内腫瘤は器質化血栓であった. 血栓摘出術とともに右房縫縮術を行った. 特発性右房拡張症はきわめてまれな疾患であり, 従来その予後は良好であるとされていた. しかし心不全や不整脈を呈して予後不良の症例の報告もあり, また手術による危険性は低いことから, 有症状例や本症例のような合併症を伴う症例には積極的に手術を行うべきであると考える.

In this article we reported a 33-year-old female patient who was referred to our emergency department with atrial fibrillation, congestive heart failure, and cardiogenic shock. In her transthoracic echocardiography, a free-floating ball-type mass was seen in the left atrial cavity with a hypertrophic cardiomyopathy. An emergency open-heart surgery was performed. The mass was removed, and pathologic examination confirmed the thrombotic material. (J Am Soc Echocardiogr 2002;15:1018-11.)

Twenty-five patients underwent resection of atrial tumors between 1970 and 1990. There were 14 primary cardiac tumors, consisting of 12 atrial myxomas, 1 angiosarcoma, and 1 fibrosarcoma. Eleven patients were excluded from echocardiographic follow-up; 7 of them had an atrial ball thrombus, and 4 had pericardial manifestations of malignant lymphomas. The remaining patients were routinely investigated by echocardiography. In 1 patient, myxoma was familial, and 2 patients had a myxoma syndrome with endocrine hyperactivity and lentiginosis. There were no operative deaths. The 2 patients with malignant tumors died three and sixteen months, respectively, after operation. All patients with atrial myxoma had follow-up by echocardiography up to eighteen years after operation with a mean follow-up of six and a half years. All patients are still alive and well. Myxoma recurred in 1 patient, detected by echocardiography on follow-up examination. Echocardiographic follow-up after myxoma resection is recommended for detection of late recurrence.

症例は69歳, 女性.心房細動を伴う僧帽弁狭窄症により通院中, 突然左半身片麻痺と意識障害で発症し入院.頭部CTでは右中大脳動脈領域に広汎な低吸収域を認め心由来の脳塞栓症と診断した.発症当日の断層エコー図上左房内に血栓を検知しなかった.発症1ヵ月後よりワーファリン投与による抗凝固療法を開始したが, 投与16日目に断層心エコー図上左房内に有茎の壁在血栓を検知し更に22日目には左房内を心拍動に伴って浮遊する径20mmの球状血栓を認めた.同日, 緊急血栓摘出術を施行し径24mm, 5.6gの球状血栓と左心耳の壁在血栓を摘出した.以上の結果より脳塞栓を来たした心房細動を伴うリウマチ性僧帽弁狭窄症例では発症直後に左房内血栓が認められない場合にも断層心エコー法による経時的な追跡が必要と考えられた.

Two rare cases of right atrial pedunculated ball thrombus associated with constrictive pericarditis and systemic lupus erythematosus are reported. Under cardiopulmonary bypass, the large thrombus in each patient was removed with care to avoid pulmonary embolism. Both patients have been doing well postoperatively and warfarin has been administered to prevent a recurrence of intracardiac thrombotic episodes.

A 70-year-old female patient was admitted to our department with symptoms and signs of acute heart failure and near syncope. After hospitalization, both transthoracic echocardiography (TTE) and subsequent transesophageal echocardiography (TEE) demonstrated a giant (4.9×3.9 cm) mobile, irregular, bright left atrial mass consistent with left atrial ball thrombus (LABT).The mass was found to occlude the left ventricular inflow tract (LVIT) above the mitral orifice (supravalvular) in the presence of normal mitral leaflets. After emergent surgical excision, the pathology of the left atrial mass was found to be consistent with thrombus. The case presented here suffered acute diastolic heart failure and near-syncope due to obstruction of the LVIT above the mitral orifice by a giant LABT. © The Author 2007., Yalta, K.; Department of Cardiology, Cumhuriyet University, Sivas 58100, Turkey; email: kyalta@gmail.com

Left atrial (LA) ball thrombus is a rare disorder. These ball thrombi are generally associated with mitral stenosis, and the restricted mitral orifice encloses the free-floating thrombus in the LA. There is a potential for fatal systemic emboli or mitral valve orifice occlusion that may result in sudden death. We report the case of a patient with tight rheumatic mitral stenosis in whom a ball thrombus was observed to bounce and rebound off the walls of LA on echocardiography. After the patient received anticoagulant therapy for 1 month, the thrombus was not found at surgery.

Reports of left atrial ball thrombus without mitral valve disease are few. We experienced a case of free-floating left atrial ball thrombus that developed in a short period in a patient with atrial fibrillation and dilated left atrium but intact mitral valve. Surgical removal of the thrombus was performed. It was presumed that atrial fibrillation and enlarged left atrium were the contributory factors to thrombus development.

This report describes alteration of surgical management in a patient with a large free-floating ball thrombus in the left atrium, which was embolized before sternotomy as demonstrated by intraoperative transesophageal echocardiography. Due to new findings observed by intraoperative transesophageal echocardiography, unnecessary sternotomy could be avoided. (ECHOCARDIOGRAPHY, Volume 20, April 2003)

1. Wrisley D, Giambartolomei A, Lee I, Browntee W. Left atria1 ball thrombus: Review of clinical and echocardiographic manifestations with suggestions for management. AM HEART J 1991;121:1764-90. 2. Wrisley D, Giambartolomei A, Levy I, Brownlee W, Lee I, Erickson J. Left atria1 ball thrombus: apparent detachment following initiation of anticoagulant therapy. AM HEART J 1988;116:1351-2. 3. Tsuda Y, Satoh K, Matsuo H. Formation of left atria1 ball thrombus during anticoagulation in a case of cerebral embolism. Stroke 1990;21:1375-6. 4. Habibzadeh M. Left atria1 thrombus despite anticoagulant therapy in a patient with mitral valve prosthesis. South Med J 1980:73:824-5.

Left atria1 thrombus formation is a common complication of rheumatic mitral stenosis. Rarely, a mural thrombus breaks free, forming a free-floating ball thrombus that increases the risk of embolization to peripheral or cerebral vessels or of obstruction of left ventricular inflow. We describe recurrence of left atria1 ball thrombus formation after surgical thrombectomy. A 78-year-old woman was admitted with complaints of weakness and falling while standing. Rheumatic fever had developed in the patient at age 15 and she showed symptoms of rheumatic mitral stenosis at age 40. She subsequently underwent an open mitral commissurotomy for mitral stenosis 30 years before this presentation. From a

A patient in whom a free-floating but immobile ball thrombus developed in the left atrium in association with mitral stenosis is reported. Certain unusual echocardiographic findings are described.

An atrial ball thrombus freely floating in the left atrium in a patient with mitral stenosis is a rare and dangerous event. In this case report we present a patient with mitral stenosis in whom the presence of a left atrial ball thrombus was documented by two-dimensional echocardiography. The association of mitral valve obstruction, the appearance of severe neurologic impairments, the typical echocardiographic pattern of the mass, and the surgical findings are described

We report a case of left atrial ball thrombus managed successfully by surgery. This is a rare clinical entity and has been reported quite infrequently in Indian literature despite the high incidence of Rheumatic mitral stenosis. The relevant literature is reviewed.

Left atrial thrombi are not infrequent in patients with mitral stenosis. Occasionally, free-floating thrombi have been reported in these patients. We report on the echocardiographic and Doppler findings in a patient with mitral stenosis.