Left atrial ball valve thrombus. Treatable cause of clinical deterioration in a patient with mitral stenosis.

Abstract

SUMMARY A 74 year old woman with mixed mitral valve disease presented with episodes of loss of consciousness and fainting. The attacks were noted to be closely related to posture, especially crouching, and this, with the clinical finding that the radial pulse disappeared before she lost consciousness, suggested the diagnosis of a ball valve thrombus. Cardiac catheterisation confirmed the diagnosis but was followed by a fall in blood pressure necessitating emergency surgery. The only position in which the circulation could be maintained was the right lateral, with steep head down tilt, and left femoro-femoral cardiopulmonary bypass had to be established in this position. Operation confirmed the presence of a ball valve thrombus and the patient recovered uneventfully.Left atrial ball valve thrombi and left atrial myxomata are well recognised causes of circulatory obstruction. The former have seldom been reported: they are easily removed surgically but the diagnosis is rarely made before death. Case reportThe patient, a 74 year old housewife, had rheumatic fever as a child. In 1969 she was admitted to hospital with a right lobar pneumonia and the signs of mild mixed mitral valve disease were noted; she was in sinus rhythm and the chest radiograph showed moderate cardiac enlargement. In 1976 she suffered a right hemiplegia but recovered completely within a few days. In November 1980 she presented with a six month history of progressive congestive failure despite digoxin and diuretics, and a six week history of dizziness associated with chest pain and blackouts.On examination she was alert with peripheral cyanosis, a small amplitude regular arterial pulse, blood pressure 110/70 mmHg, a venous pressure of +8 cm, 4 cm hepatomegaly, and ankle oedema: she was apyrexial. There was a parasternal heave, an apical pansystolic murmur, a late opening snap, and a full length diastolic murmur. A chest radiograph showed cardiomegaly with left atrial enlargement, bilateral pleural effusions, and a prominent main pulmonary artery. Her electrocardiogram showed sinus rhythm with multiple atrial ectopic beats and digoxin effect. Full blood count was normal and erythrocyte sedmentation rate 10.Her episodes of loss of consciousness continued on the ward, up to 10 times daily, each beginning with the patient feeling dizzy and then rapidly losing consciousness. After 20 to 30 seconds she convulsed, and then recovered in a further 2 to 3 minutes. The episodes occurred in any position but became an invariable accompaniment to attempts to defaecate. Her congestive failure was increasingly resistant to treatment. It was thought that she was suffering from epilepsy caused by her previous cerebral infarct but her condition did not improve with anticonvulsants.Clinical examination during an attack, with simultaneous cardiographic monitoring, showed that the first event was a gradual weakening of the radial pulse with no alteration of rate or rhythm at a time when the cardiac impulse was still forcible. The patient then became unconscious, pulsel...

Left atrial ball valve thrombus

“…In patients with rheumatic mitral stenosis who develop a ball valve thrombus as a complication, atrial fibrillation is often present. [2][3][4] In contrast, our patient was in normal sinus rhythm, suggesting that ball valve thrombus can rarely develop in patients with normal sinus rhythm also. Clinically ball valve thrombus can produce symptoms of heart failure or embolic stroke , peripheral embolism or sudden death.…”

“…Till date, less than 60 cases have been reported till the 1980's. [2][3][4] In most of the patients presenting with a ball valve thrombus, severe mitral stenosis of rheumatic origin has been the most common predisposing condition. Our patient had severe mitral stenosis and moderately severe aortic stenosis of rheumatic origin.…”

“…With the advent of echocardiography, ball valve thrombus is being diagnosed more frequently. 2,14 Oral anticoagulation is usually avoided in these patients as this can result in fragmentation of the thrombus and embolization. Urgent and prompt surgery as was done in our patient can be life saving.…”

A Ball Valve Thrombus in a Young Obese Male With Hyperlipidemia

“…A ball valve thrombus physiologically behaves like critical mitral stenosis with an acute rise in left atrial pressure secondary to severe mitral inflow obstruction, passive pulmonary venous congestion, pulmonary edema with subsequent paroxysmal nocturnal dyspnea, and orthopnea, as noted in our patient. Besides rheumatic mitral valve disease, ball valve thrombus has been noted in degenerative mitral valve disease [ 4 ], restrictive cardiomyopathy, and post-cardiac surgery, especially prosthetic mitral valve in situ. Right atrial ball valve thrombus is a rare event to be reported in prolonged parenteral nutrition with an intrajugular central line in situ.…”