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A42 year old woman was admitted to the emergency department of our hospital with symptoms of dyspnoea and cough. On physical examination her blood pressure was 110/70 mm Hg, pulse 126 beats per minute, and she was arrhythmic. Body temperature was 38.1°C. An apical diastolic murmur could hardly be heard when the patient was in the left lateral decubitus position. There were fine pulmonary basilar rales. Neither jugular venous distension nor hepatosplenomegaly was present. Peripheral findings of infective endocarditis and Roth spots at fundoscopy were also absent.
Chest x ray demonstrated pulmonary vascular redistribution, parenchymal congestion, and bilateral pleural effusion. Atrial fibrillation was noted on the ECG. A complete blood count revealed anaemia (haemoglobin 6.6 mmol/l) and leucocytosis (18.6 × 109/l). The erythrocyte sedimentation rate was 55 mm/hour.
Transthoracic echocardiography showed normal left ventricular size and ejection fraction; the mitral valve was fibrotic and calcified, and mitral valve area measured 1.2 cm2, using planimetric and Doppler techniques.
When transoesophageal echocardiography (TOE) was performed a cystic formation was noted in the left atrium, close to the left atrial appendage. It was 21 × 17 mm in size and had smooth contours. Nodular structures were visible within the cystic formation. There was also spontaneous echo contrast in the left atrium as shown (LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; SEC spontaneous echo contrast).
Surgery was performed for mitral valve replacement and removal of the cystic mass in the left atrium. Histopathologic examination confirmed that the mass was a pure thrombus.