We have read with interest the article of Acet et al. published in this journal.
We recently had a similar case of a 61-year-old male patient with severe rheumatic mitral stenosis and atrial fibrillation.
The patient was admitted in our clinic for minimal exertional dyspnea (NYHA Class 3). Clinically, we noted the augmentation of the intensity of the first cardiac sound, complete arrhythmia corresponding with atrial fibrillation on the EKG, and hepatomegaly.
The transthoracic echocardiogram revealed a severe rheumatic mitral stenosis with a planimetric area of the mitral orifice of 0.8 cm 2 and the presence of an echogenic pediculated mass of large dimensions ( Fig. 1 ) inside the left atrium. The mass seemed to be attached to the atrial dome and was partially mobile. The left atrium was also dilated. The very severe pulmonary hypertension (140 mmHg) in the presence of the 0.8-cm 2 mitral valve area raises the question about the etiology of pulmonary hypertension: Was it secondary to mitral valve disease? Does it have an essential component or was it caused by an obstructive mechanism created by the atrial mass?
In the clinical context of this patient (mitral stenosis and atrial fibrillation), we believe that the atrial mass was a thrombus . We did not notice the angiographic aspect described by the authors, but this fact could be attributed to an old thrombus.
Our patient accepted the surgical intervention. Through left atriotomy, the surgeons found a massive left atrial thrombosis—a giant thrombus of 8/8 cm ( Fig. 2 ) adherent to the posterior atrial wall near the entrance of the right pulmonary veins, creating their partial obstruction. Thrombectomy was performed and the mitral valve was replaced with a mechanical prosthesis. The histopathologic examination confirmed the fact that the mass was a thrombus ( Fig. 3 ).
