Left Atrial “Pinball” Thrombus Causing Recurrent Syncope

Key words: cardiac imaging, thrombus, valve obstruction

A 75-year-old female with a history of rheumatic heart disease was admitted due to a syncopal episode. During the past 2 months, she reported 2 other sudden, brief episodes of syncope consistent with drop attacks. There were no premonitory symptoms suggestive of vasovagal syncope. Physical examination demonstrated an irregular rhythm and an apical diastolic murmur. Telemetry demonstrated her rhythm to be atrial fibrillation with a controlled rate. Electroencephalogram did not demonstrate seizure activity. Transesophageal echocardiography demonstrated severe mitral stenosis with a 5 x 5 cm, free-floating, left atrial thrombus intermittently obstructing the mitral valve orifice, which was bouncing off the mitral valve much like a pinball. These findings were confirmed on transesophageal echocardiography (Figures 1-4 and Video 1). The patient underwent removal of the thrombus along with mitral valve replacement, and was placed on chronic anticoagulation. She did not have any further syncopal episodes at 1-year follow-up exam.

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From ¹the Department of Anesthesia, Mount Sinai Medical Center, Miami Beach, Florida; ²Johns Hopkins University, Baltimore, Maryland; and ³the Echocardiography Laboratory, Columbia University Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, Florida.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted April 10, 2019.

Address for correspondence: Nicholas Suraci, MD, Department of Anesthesiology, 4300 Alton Road, Miami Beach, FL 33140. Email: nicholas.suraci@gmail.com