A 49-year-old woman was admitted to the Sina Heart Institute in Isfahan in Iran for mitral valve replacement on 18 July 2011. She had become progressively symptomatic since September of 2008. An irregular heartbeat had been present for many years. During the past several years, her physical activities were reduced significantly and she had recently become more symptomatic. Medical therapy of the patient included digoxin, diuretic and warfarin.
On admission the patient had an irregular pulse with an apical rate of 80-100 beat/min. The first heart sound was increased; a loud opening snap and a long, grade 3/6, diastolic, rumbling murmur, in addition to grade 3/6 pan systolic murmur were best heard at the apex in the fifth intercostal space in mid-clavicular line. Electrocardiography showed atrial fibrillation with a ventricular rate of approximately 80-100 beat/min and nonspecific ST-T changes. Last echocardiography showed severe mitral stenosis (MS) and regurgitation. Angiography of coronary arteries was normal.
Intra operative TEE was done just few min before surgery. Ejection fraction was 40%. There were mitral stenosis and mitral regurgitation 3/4+. Echocardiography revealed left atrial and ventricular enlargement; the mitral valve configuration was consistent with calcific mitral stenosis. Investigation of LA and LAA did not show clot [Figure 1].
At open heart surgery, replacement of the mitral valve was performed and it replaced with artificial valve. Left atrial appendage occlusion was done during surgery. Post-pump TEE demonstrated an echo imitated the presence of a clot in left atrial appendage area [Figure 2]. Indeed thrombus was filled the LAA and this thrombus would be organized with no chance of emboli. The post-operative course was uneventful, and the patient was discharged on 27 July 2011.