An Unusual Case of Multi-Chamber Thrombi in a Patient with Mitral Valve Repair

A 55-year-old man with a history of non-ischaemic cardiomyopathy and implantation of a biventricular pacemaker with a defibrillator was referred for evaluation for a heart transplant because of New York Heart Association class IV heart failure symptoms. Four months earlier, he had undergone mitral valve repair for severe mitral regurgitation.

Transthoracic echocardiography showed severe bi-atrial enlargement, marked reduction in left ventricular systolic function, and evidence of prior mitral valve repair using an annuloplasty ring. The initial apical long-axis view of the left ventricle showed no obvious left atrial thrombus (Figure 1A), but a mobile density was attached to the anteroseptal and anterior walls consistent with a left ventricular thrombus. The short-axis view of the left ventricle at the mid-ventricular level also showed a thrombus attached to the anterior wall (Figure 1B). However, additional imaging of the left atrium clearly showed a thrombus along the lateral wall (Figure 1C). Subsequent intra-operative transoesophageal echocardiography before implantation of a CardioWest total artificial heart (Syncardia Systems Inc, Tucson, Arizona) showed left atrial and ventricular thrombi (Figure 1D), which were later confirmed during surgery along with a smaller right atrial thrombus.

This case illustrates the uncommon finding of biatrial thrombi in a patient with severely reduced left ventricular function following mitral valve repair. Specifically, atrial thrombi can be missed once left ventricular thrombus is found unless there is high index of clinical suspicion. Our case underscores the need for careful echocardiographic evaluation of all chambers after discovery of a thrombus.

Funding / potential competing interests

No financial support and no other potential conflict of interest relevant to this article were reported.