Author + information
- Received May 20, 2011
- Revision received July 11, 2011
- Accepted July 19, 2011
- Published online April 10, 2012.
A 63-year-old woman, originally from China with a history of rheumatic heart disease and chronic atrial fibrillation (AF) taking no anticoagulation drugs (A), presented with pulmonary edema. Her echocardiogram showed severe mitral stenosis and moderate pulmonary hypertension (Online Video 1). A transesophageal echocardiogram (B, Online Videos 2 and 3) confirmed the presence of a very large left atrial (LA) mass (T). A coronary angiogram revealed multiple fistulae (*) from the circumflex artery (CX) to the LA (C and D, Online Videos 4 and 5). The patient declined further investigations including biopsy of the mass and surgical intervention on the mitral valve and the mass. She is currently maintained on oral anticoagulation therapy. Given the underlying rheumatic mitral stenosis, dilated LA, chronic AF with no anticoagulation therapy, and a mass originating from the LA appendage, a thrombus was considered the most likely possibility.
Fistulous communication due to neovascularity within the LA thrombus was initially described by Soulen et al (1). In a large series, 40% of patients with LA thrombus were found to have such neovascular connections (2). LAD = left anterior descending; RA = right atrium.
- Received May 20, 2011.
- Revision received July 11, 2011.
- Accepted July 19, 2011.
- American College of Cardiology Foundation