Moving Ball in Left Atrium-Presenting as Recurrent Syncope
In patients with rheumatic mitral valve stenosis having atrial fibrillation, the “Ball valve thrombus” is an uncommonly encountered complication. A case of 42-year-old male with rheumatic severe mitral stenosis, mild aortic stenosis with moderate regurgitation presented with recurrent episodes of non-exertional syncope for seven days as chief symptom. He was in atrial fibrillation with controlled ventricular rate and echocardiography, showed a large ball valve thrombus in the left atrium. Thus, echocardiography facilitated for rapid diagnosis and earliest surgical intervention as a life saving measure.
A 42-year-old male, singer by profession, presented with recurrent non-exertional syncope for seven days without history of palpitation, dyspnoea, paroxysmal nocturnal dyspnoea. On further evaluation, pulse rate was irregular and rate was 70/min; blood pressure was 120/80 mm Hg in the right arm in supine position. Cardiovascular system examination revealed features suggestive of severe mitral stenosis and mild aortic stenosis and moderate regurgitation. He never visited any physician for his illness. On further investigation, ECG showed atrial fibrillation with controlled ventricular rate [Table/Fig-1]. His echocardiogram was suggestive of severe mitral stenosis, moderate aortic regurgitation with mild stenosis. There was a large freely mobile thrombus measuring 23×24 mm in left atrium, frequently impinging on stenotic mitral valve orifice [Table/Fig-2] and [Video-1-3]. He was immediately started on anticoagulation and referred for mitral valve replacement and clot removal.
ECG showing atrial fibrillation.
(a) Showing thrombus in left atrium protruding into mitral valve; and (b) Showing free ball-valve thrombus.
In rheumatic mitral valve disease, left atrial thrombosis is a frequent entity . It is more commonly seen in enlarged atrium with atrial fibrillation . Around one third of patients with rheumatic severe mitral stenosis with atrial fibrillation will have left atrial thrombus . The prevalence of ball-valve thrombus in such a population is not well documented in the literature. The common complication of ball valve thrombus is systemic embolization, heart failure, Cerebrovascular Accident (CVA) or sudden cardiac death . Our patient presented with recurrent non-exertional syncope as his chief complaint, which is a well described feature in ball valve thrombus . It is hypothesised that the ball valve thrombus is initially formed in the left atrial appendage which subsequently extends into the left atrium and later, this spherical-shaped thrombus when gets disconnected from the left atrial wall, spins at a random speed in a clockwise direction . In systole, it is propelled backwards into the left atrium by the anterior mitral leaflet causing intermittent ping-pong acceleration . This results in intermittent left ventricular inflow obstruction causing syncope.
Echocardiography is an easily accessible and non-invasive tool for prompt diagnosis of these conditions. Emergent surgery to remove the ball valve thrombus should be considered given its potential life threatening nature .
In rheumatic heart disease, mitral stenosis is common valvular lesion where left atrium thrombosis occurs commonly. If the thrombus becomes large and freely mobile and obstructs the mitral inflow, the patient may present as recurrent syncope. Prompt surgical intervention is life-saving.
Parasternal long axis view showing large left atrial thrombus causing obstruction of mitral valve.
Apical four chamber view showing freely mobile left atrial thrombus.
Apical 5 chamber view showing freely mobile left atrial thrombus abutting mitral orifice.
. Malaga P, Pocock WA, Two-dimensional and Doppler echocardiographic features of a left atrial ball thrombus Echocardiography 1997 14(4):383-86.10.1111/j.1540-8175.1997.tb00738.x [Google Scholar] [CrossRef]
. Conradie C, Schall R, Marx JD, Left atrial size a risk factor for left atrial thrombi in mitral stenosis Clin Cardiol 1995 18(9):518-20.10.1002/clc.49601809077489608 [Google Scholar] [CrossRef] [PubMed]
. Srimannarayana J, Varma RS, Satheesh S, Anilkumar R, Balachander J, Prevalence of left atrial thrombus in rheumatic mitral stenosis with atrial fibrillation and its response to anticoagulation; A transesophageal echocardiographic study Indian Heart J 2003 55(4):358-61. [Google Scholar]
. Lie JT, Entman ML, ‘Hole-in-one’ sudden death: mitral stenosis and left atrial ball thrombus Am Heart J 1976 91:798-804.10.1016/S0002-8703(76)80546-7 [Google Scholar] [CrossRef]
. Fraser AG, Angelini GD, Ikram S, Butchart EG, Left atrial ball thrombus: echocardiographic features and clinical implications Eur Heart J 1988 9:672-77.10.1093/oxfordjournals.eurheartj.a0625603409899 [Google Scholar] [CrossRef] [PubMed]
. Yoshida K, Fujii G, Suzuki S, Shimomura T, Miyahara K, Matsuura A, A report of a surgical case of left atrial free floating ball thrombus in the absence of mitral valve disease Ann Thorac Cardiovasc Surg 2002 8(5):316-18. [Google Scholar]
. Grandmougin D, Letourneau T, Favre JP, Baral X, Paroxysmal postural dyspnea related to a left atrial ball thrombus Ann Thorac Surg 2002 74:1691-94.10.1016/S0003-4975(02)03858-4 [Google Scholar] [CrossRef]