Coronary neovascularization as a specific sign for left atrial appendage thrombus in mitral stenosis

An Unusual Case of Cardiac Mass: A Multimodal Approach in Diagnosis and Treatment

Diagnosing intracardiac masses poses a complex, multimodal challenge. We present the case of a 72-year-old woman with a history of rheumatic fever leading to mitral stenosis and a previous mitral valve commissurotomy who reported fatigue, weakness, and palpitations over the past three months. Echocardiography revealed a tumor (53 × 40 mm) in the enlarged left atrium, attached by a wide base to the left atrium wall, exhibiting variable densities. Computerized tomography identified a heterodense mass (53 × 46 × 37 mm) with similar attachments. Angiography showed two branches from the circumflex artery intricately associated with the mass. Despite unsuccessful embolization of the mass' blood supply, surgical intervention including mitral valve replacement, tricuspid valve annuloplasty, and tumor removal was pursued. Pathohistological analysis confirmed the mass as a thrombus. During the postoperative follow-up, the patient presented with no complaints. Follow-up echocardiography indicated the normal function of the mechanical mitral valve prosthesis and the absence of intracardiac masses. While it remains unknown whether this neovascularization is specific to patients with severe mitral valve disease, this case highlights the diagnostic challenges of differentiating between thrombi and tumors in the context of mitral valve disease. It illustrates the critical role of multimodal imaging in elucidating the anatomical and functional relationships within the heart, thereby guiding accurate diagnosis and effective treatment.

Left circumflex coronary artery to left atrial fistula in a patient with mitral regurgitation after excision of a left atrial myxoma

Acquired coronary artery to left atrial fistulas are rare and previously only described in mitral stenosis associated with left atrial thrombus or coronary arteriosclerosis. We present the case of a patient who developed a left circumflex coronary artery to left atrial fistula associated with mitral regurgitation 12 years after excision of a left atrial myxoma. This was successfully ligated at the time of mitral valve replacement.

Coronary angiographic finding of thrombus in the left atrial appendage

PURPOSE

The value of coronary angiography in the diagnosis of thrombus in the left atrial appendage (LAA) was retrospectively analyzed.

MATERIAL AND METHODS

The study covers 34 patients in whom coronary angiography showed coronary neovascularity in LAA with coronary artery-left atrial fistula indicating LAA thrombus. All 34 patients underwent transthoracic echocardiography within one week of coronary angiography. Open-heart surgery was undertaken 2-31 months after angiography in 28 patients.

RESULTS

Coronary neovascularity and coronary artery-left atrial fistula arose from the left circumflex artery in 28 patients, and from the left circumflex artery and the right coronary artery in the remaining 6 patients. By echocardiography, LAA thrombus was detected in only one of the 34 patients. In 18 of the 28 patients who underwent open-heart surgery, LAA thrombus was found at surgery to have resolved.

CONCLUSION

Coronary angiography is useful in the diagnosis of LAA thrombus, and coronary neovascularity and fistula formation may indicate that the thrombus can spontaneously resolve.

Left circumflex coronary artery to left atrial fistula in a patient with mitral stenosis: invasive and noninvasive findings with pathophysiologic correlation

We report a case of an angiographically documented fistula between the circumflex coronary artery and a left strial appendage thrombus in a patient with mitral stenosis, flow from which can be demonstrated solely by a color doppler transesophageal echocardiogram. Evaluation of catheter derived hemodynamics and angiographic flow patterns reveals a heretofore undescribed physiologic property of coronary to atrial shunts in patients with mitral stenosis.

Late neovascularization of longstanding left ventricular mural thrombus--a case report

Serial coronary angiography done in a patient with left ventricular mural thrombus demonstrated abnormal neovascularity from the coronary artery to the left ventricle occurring eight to eighteen months after thrombus formation. This is the first case report describing such late neovascularization of left ventricular mural thrombus. The formation of coronary neovascularity to left ventricular mural thrombus need not occur in the early stage of the thrombus.

Contrast transesophageal echocardiographic demonstration of coronary artery fistula within left atrial appendage thrombus in mitral stenosis

Coronary neovascularization and fistula formation arising from the left circumflex artery demonstrated by coronary angiography is a specific sign for the presence of left atrial appendage thrombus in patients with mitral stenosis. However, the fistula drainage site in the left atrium in relation to the thrombus cannot be ascertained by the angiographic method. We performed transesophageal echocardiography simultaneously with coronary angiography in five patients with severe mitral stenosis and left atrial appendage thrombus. The angiography showed coronary neovascularization and fistula arising from the left circumflex artery in three patients. In these three patients, the transesophageal echocardiography confirmed the presence of a coronary fistula by identifying contrast exuding from the surface of the thrombus. Thus we have shown for the first time the usefulness of contrast transesophageal echocardiography in imaging the exact drainage site of coronary artery fistula from left atrial appendage thrombus.