Embolization of a left atrial ball thrombus during transesophageal echocardiography

[Mobile and obstructive thrombus of the left atrium. Value and risks of transesophageal echocardiography. Report of a case and review of the literature]

Authors report the observation of a young woman of 30 years hospitalised for degeneration of a mitral biologic prosthesis. Transthoracic echocardiography visualizes a voluminous mass of the left auricle of which the character free and destitute of all parietal attachment, doesn't have can be established that by transoesophageal echocardiography that detects another thrombus also free and mobile of the left auricule, unrecognised by transthoracic way. The operative indication is carried in emergency but the patient dies suddenly some hours after this exam. From this observation and a revue of the literature, the contribution and risks possible transoesophageal echocardiography in the exploration of the mobile thrombi of the left auricle, are analysed. Account-held of the potential gravity of homodynamic and embolic complications, the emergency of the surgical indication is underlined.

[A rare case of 2 free thrombi in left atrium with mitral stenosis]

A 64-year-old female was admitted with general fatigue and orthopnea. Preoperative echocardiography showed a free ball thrombus in the left atrium, mitral stenosis and severe tricuspid regurgitation. To avoid a herniation of thrombus to the mitral orifice, an emergency operation was performed. Two free and small mural thrombi were found in the left atrium. Thrombectomy, mitral valve replacement and tricuspid annuloplasty were performed successfully. Postoperative course was uneventful, and she was discharged in good condition on the 21st postoperative day.

The effect of body position on a free-floating ball thrombus as observed by transesophageal echocardiography

Two cases of free-floating left atrial ball thrombi (FLABT) in association with mitral stenosis were observed by transesophageal echocardiography (TEE). Our report describes the relation between body position and thrombi kinetics. Both cases demonstrated similar kinetics. In the supine and right lateral decubitus positions, the thrombi recoiled from and sometimes became entrapped within the mitral valve. In the sitting and left lateral decubitus positions, the thrombi appeared to be nearly fixed and did not contact with the mitral valve. Our results indicate that the latter two positions prevent thrombi disintegration and incarceration into the mitral valve. Finally, TEE is an extremely useful tool for assessing the safest position for individuals with FLABT.

Usefulness of transesophageal echocardiography for guiding pulmonary artery catheter placement in the operating room

The usefulness of transesophageal echocardiography (TEE) for guiding the placement of a pulmonary artery (PA) catheter was evaluated in 31 patients (TEE group); 31 patients who were treated before TEE guidance was used (control group). In the control group, use of the PA catheter was abandoned in two patients; because of an unstable condition and marked arrhythmias, respectively. The key findings for TEE guidance were: (1) pulsatile to-and-fro movement of the balloon, i.e., "shuttle movement" and (2) loss of shuttle movement at wedging of the balloon, i.e., "anchoring sign." When the PA catheter did not enter the right vertricle (RV), the balloon was found to be in the inferior vena cava or the right atrium (RA) without shuttle movement. Coiling of the catheter was suggested in the latter situation. Coiling also occurred in the RV, often associated with frequent arrhythmias. These findings indicate that the catheter should be withdrawn once. TEE allowed for readjustment of the catheter tip position by enabling the balloon to be wedged twice. An excessively deep placement of the catheter tip was seen in 5 of the controls, but in none of the TEE group. Biplane TEE was found to be advantageous for guiding PA catheter placement and for visualizing the RV inflow and outflow tract in a single view, with the shuttle movement of the balloon in its long axis. TEE acts as an "eye" in the operating room, as does fluoroscopy, enabling smooth placement of the PA catheter.