• Images in cardiology

Patients with left atrial thrombus are considered at high risk for thromboembolic events. Transoesophageal echocardiography (TOE) is highly accurate for diagnosis of atrial thrombi and gives the possibility to serially evaluate the effects of anticoagulant treatment.

We present the case of a 79 year old woman who was admitted to the hospital suffering from acute stroke. She had a history of coronary artery disease, chronic atrial fibrillation, and permanent pacemaker. She was not treated with anticoagulants. Clinical diagnosis was confirmed by brain computed tomography, which showed two infarcts in the right posterior cerebral artery perfusion area and a third haemorrhagic infarct in the left middle cerebral artery perfusion area. She underwent a TOE study, which showed a large thrombus, partly mobile, on the posterior atrial wall (dimensions: 2.71 cm length and 2.19 cm width; surface area 4.45 cm²) (middle panel: A, length; B, width; C, surface area; LA, left atrium; THRO, thrombus). The patient started anticoagulation treatment (acenocoumarol). The thrombus size remained unchanged in a second study seven days later, while a new TOE 20 days later showed a slight decrease of the thrombus dimensions (2.44 cm length and 1.68 cm width, surface area

3.31 cm²) (right upper panel: AO, aorta, RA, right atrium). The patient’s condition improved steadily and she was discharged from hospital 20 days after the start of anticoagulation treatment. Forty days later the TOE showed complete resolution of atrial thrombus (right lower panel). The TOE study remained unchanged five months and two and a half years later, while the patient’s condition further improved.

The striking clinical finding was that the thrombus resolution was not accompanied by any new neurological events, even though its size was significant.