A pinball game in the left atrium.

摘要: In January, 2011, a 64-year-old woman presented to us with atwo-week history of fatigue, dizziness, dyspnea on exertion, andpain in the fourth and fifth toes her left foot. One year before, shewas diagnosed atrial fibrillation moderate rheumaticmitral valve stenosis. On that occasion, transesophagealechocardiography showed mural thrombus stuck posteriorwall atrium, whose diameters were 3×5 cm. Therefore,anticoagulation warfarinwas begun. A follow-up echocardiogra-phy documented persistence five months beforepresentation, despite regular anticoagulation. Her thrombophiliawork-up was negative. physical examination there inceptivegangreneof fingertipof fourthtoe She had pal-pable bilateral femoral, popliteal, posterior tibial pulse re-duced dorsalis pedis pulse. Heart auscultation notable for aloud first heart sound, an opening snap, mid-diastolic murmur.The murmur changed intensity randomly, independently by posi-tion patient or inspiration. Chest radiographyrevealeda dilatedleft pulmonary venous congestion, enlarged pulmonaryartery.ECG atrialfibrillation. Transthoracic echocardiographyrevealed large highly mobile mass atrium. Transoesopha-geal echocardiography round floating atrialchamber,withoutevidenceof anyattachment. (Fig.1, Videos1and 2)The measured 2.8×2.1 cm occasionally obstructed mi-tral orifice during diastole without passing through. systolethe pushed back atrium mitral leaflets,thus mimicking pinball game. There no more evidence thevoluminous before. Theanticoagulation suspended surgery planned. Threedays after underwent cardiac removal atrialmass replacement. Exploration atriumrevealed spherical, smooth, non-pedunculated free inthe cavity (Fig. 2). The replaced using St.Jude Medical mechanical valve. Amputation affected toeswas performed concurrently. postoperative course unevent-ful. Histology confirmed thrombus, cov-ered endothelial cells.Atrial free-floating ball wasfirst described Woodin 1814 autopsy 15-year-old girl steno-sis [1]. Free-floating thrombi are rare condition occurring nearlyalways patients stenosis, particu-larly when atrialfibrillation is present. While non-valvular usually develop thrombosis leftappendage, located body com-moninpatientswithmitralstenosis[2]. existence muralthrombus crucial formation thrombus.In our case, we pre-existing few before presentation. This evidencestrongly suggests it dropped off spontaneously atrium,maybe facilitated fact, wascovered endothelium, thus suggesting probably old andmore resistant dissolution. Symptoms include failure andsyncope intermittent obstruction systemicembolism fragmentation. Sudden death due incarcerationof into has been [3].Our which couldnot be explained disease, initial gan-grene toes, embolization. It likely thatsymptoms started detachment from atrialwall. Although current guidelines recommend anticoagulation inpatients stenosis[4],inthispartic-ular scenario may not useful poten-tially harmful. Surgery treatment choice since permitsthe underling valvedisease.Supplementary materials related this article can foundonline at doi:10.1016/j.ijcard.2011.12.002.