Mitral Stenosis with Multiple Left Atrium Thrombus: a Case Report

R. Afifah, L. Elfira, D. Reyhani, R. D. W. Satiti

Departement of Cardiology and Vascular Medicine
Faculty of Medicine Andalas University/ Dr. M Djamil General Hospital, Padang

Introduction:
Mitral stenosis is form of valvular disease characterized by narrowing of the mitral valve
orifice. This disease have high prevalency in developing countries. The most common cause
of mitral stenosis is rheumatic mitral stenosis which often associated with thrombus formation
in the left atrium (LA).
Case Illustration:
We reported the case of a 47-year-old female presented with progressive dyspnea with an
increased of severity within a month. She had a 7 month history of dyspnea d’effort, orthopnea
and paroxysmal nocturnal dyspnea. From physical examinations found JVP 5+0 cm H2O,
inspection ictus cordis is not visible, palpation ictus cordis palpable 2 finger lateral LMCS 6th
ICS, percussion upper 2nd ICS, right right sternal border, left 2 finger lateral LMCS 6th ICS,
and auscultation S1 S2 ireguler, diastolic minimal 2/4 on apex, gallop (-), murmur (-). ECG
showed AF with QRS rate 90-100x, normal axis, QRS duration 0,08 s, inverted T wave at V4-
V6, no LVH or RVH was found. Echocardiography revealed mitral stenosis severe, AR mild,
TR mild e.c RHD, multiple thrombus on left atrial, and myxoma on interatrial septum with
pedicle. Patient then diagnosed with mitral stenosis with multiple left atrial thrombus. She
received UFH, furosemide, beta blocker, angiotensin receptor blocker, and warfarin during
hospitalization.
Discussion:
The cause of mitral stenosis are, rhemautic fever, scarring and fusion of valve apparatus, rarely
congenital, and female. Mitral stenosis in this patient probably caused by rheumatic fever.
Two-third of all patient with mitral stenosis are female. Dyspnea d’effort, orthopnea,
paroxysmal nocturnal dyspnea, and chest palpitation are useful signs that point to diagnostic.
Echocardiography will usually reveal the diagnostic.
Left Atrial thrombus caused by the primary antiphospholipid syndrome causing critical
functional mitral stenosis, usually seen in severe mitral stenosis caused by rheumatic fever
with atrial fibrillation. The clinical diagnosis of LA thrombus confirmed with
echocardiography with transesophageal approach as the best choice. It also helps in guiding
therapy designed to reduce thromboembolic risk.
Management of these patient are anticoagulant and thrombolytic therapy that help in the
prevention of its further progression. It can cause potential life threatening embolism and
circulatory collapse. Therefore these patient need urgent surgical removal of thrombus with
correction of the underlying cause and produces long term survival .