alexa Left Atrial Slow Flow and Its Potential Complication | Open Access Journals
ISSN: 2329-9517
Journal of Cardiovascular Diseases & Diagnosis
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Left Atrial Slow Flow and Its Potential Complication

Suthipong Soontrapa1, Ralph Paone2, Leigh Ann Jenkins1, Gary Meyerrose1 and Aliakbar Arvandi1*
1Division of Cardiology, Department of Internal Medicine, Texas Tech Health Sciences Center, Texas, USA
2Department of Surgery, Texas Tech University Health Sciences Center, Texas, USA
Corresponding Author : Aliakbar Arvandi
Division of Cardiology, Department of Internal Medicine
Texas Tech University Health Sciences Center, 3601 4th Street
Stop 9410, Lubbock, Texas, 79430-9410, USA
Tel: +1806-7433155
Fax: +1806-7433148
E-mail: [email protected]
Received January 24, 2014; Accepted February 26, 2014; Published March 05, 2014
Citation: Soontrapa S, Paone R, Jenkins LA, Meyerrose G, Arvandi A (2014) Left Atrial Slow Flow and Its Potential Complication. J Cardiovasc Dis Diagn 2:147. doi: 10.4172/2329-9517.1000147
Copyright: © 2014 Soontrapa S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Related article at
DownloadPubmed DownloadScholar Google

Visit for more related articles at Journal of Cardiovascular Diseases & Diagnosis

Abstract

It has been estimated that 2.2 million people in United States have paroxysmal or persistent atrial fibrillation. The incidence has increased 13% over the past 20 years and it seems to be on the rise. The most feared complication of atrial fibrillation is systemic thromboembolic events. Mitral stenosis and atrial fibrillation is risk factors for cardiac thrombus formation. We report an interesting case in which a 69-year-old male with rheumatic mitral stenosis, atrial fibrillation and congestive heart failure developed rapidly worsening dyspnea on anticoagulation. Subsequent investigation demonstrated impaired left ventricular systolic function, severe mitral valve stenosis and a large left atrial thrombus.

Since the patient’s symptoms had worsened rapidly during a relatively short period of time, we hypothesize that the thrombus was obstructing blood flow through the left atrium and was causing the patient’s symptoms. Mitral valve stenosis, itself, is a risk factor for thromboembolic events. Combined with atrial fibrillation and left ventricular systolic dysfunction, slow flow in the left atrium may contribute to thrombus formation.

Even though, our patient was anticoagulated, the stability of oral anticoagulation therapy is essential. We want to highlight one particular group of patients, classified as high risk, in which close clinical follow-up and more intense anticoagulation might be of benefit. Also, the possibility of thrombus formation in the left atrium should be considered when there is a sudden change in symptoms

Introduction
It had been estimated that 2.2 million people in United States have paroxysmal or persistent atrial fibrillation (AF). The incidence has increased 13% over past 20 years and it seems to be on the rise [1,2]. Severe mitral valve stenosis results in left atrial dilatation and is frequently associated with AF. Mitral stenosis and AF are risk factors for cardiac thrombus formation. This risk increases when the problems are combined. Recent studies show that the prevalence of left atrial thrombus in the patient with mitral valve stenosis in normal sinus rhythm is 6.6% compared with 38% in patient with AF [3,4].
The most feared complication of left atrial thrombus is systemic embolization, which occurs in 10-45% of patients with mitral stenosis [5]. The presence of left atrial thrombus also has important therapeutic implications, not only in terms of anticoagulation, but also the possible need for valve replacement.
We present an interesting case in which a male with mitral stenosis and AF developed rapidly worsening dyspnea most likely due to the increase in size of thrombus in the left atrium while the patient was anticoagulated.
Case Presentation
A 69 year-old Hispanic male with diabetes, hypertension, stroke, coronary artery disease, cardiomyopathy, rheumatic mitral valve stenosis and chronic AF presented with rapidly increasing shortness of breath. The patient reported rapidly declining functional capacity during the 4 weeks period prior to evaluation. The patient complained of lack of energy and the development of paroxysmal nocturnal dyspnea. Physical examination demonstrated an elderly male in no distress, normal vital signs, irregularly irregular rhythm with grade 1 diastolic rumbling murmur without radiation.
The patient has a known history of rheumatic mitral valve disease. He had balloon valvuloplasty in 1999. He then developed AF with cerebrovascular accident in 2001, and anticoagulation therapy was initiated.
Transesophageal (TEE) echocardiography demonstrated decreased left ventricular systolic function with ejection fraction of 35-39%. It also revealed severe mitral valve stenosis with effective orifice area of 0.8 cm2 and the presence of a large echogenic mass in the left atrial appendage extending into the left atrium. Subsequent coronary angiogram showed no significant coronary artery disease (Figure 1). Mitral valve replacement and thrombus removal were performed (Figures 2 and 3). A left atrial mass was confirmed to be thrombus with histopathology.
Discussion
This case is interesting in that it demonstrates both 2-Dimensional and 3-Dimensional echocardiographic images of both the left atrial thrombus and the mitral valve stenosis (Figure 4-6). Despite the large size of the left atrial thrombus, this thrombus was visualized on TEE images, but was not seen on transthoracic images. Since the patient’s symptoms had worsened rapidly during a relatively short period of time, we hypothesize that the thrombus was obstructing blood flow through the left atrium and was contributing to the patient’s symptoms. It is reasonable to assume that the patient’s dyspnea was a result of both his mitral stenosis and the thrombus in combination, limiting forward blood flow.
It is interesting that such a large left atrial thrombus could develop in a patient who was receiving anticoagulation. Estimating the risk of stroke for individual AF patients is crucial in making the decision to provide anticoagulant therapy. The threshold risk which warrants anticoagulation is controversial. Recent guidelines suggest that patients with a stroke risk of 2% per year or less (classified as low risk) do not benefit substantially from oral anticoagulation [6]. For high-risk AF patients with stroke rates of ≥ 6% per, the comparable number neededto- treat is 25 or fewer, strongly favoring anticoagulation.
Recent studies also include systolic heart failure (HF) with decreased ejection fraction as a “moderate-risk factor” as it is thought to cause increased risk for stroke and thromboembolic complications. Some reports demonstrate that patients with HF are hypercoaguable because of increased platelet activation and elevated coagulation markers such as D-dimer, thromboglobulin, and thrombin-antithrombin III complexes which could lead to thrombus formation [6].
Our patient presented with worsening shortness of breath which initially was thought to be secondary to progression of mitral valve disease. Subsequent investigation demonstrated a giant left atrial thrombus. Regarding risk stratification, our patient was classified as having ‘high’ risk due to prior stroke and rheumatic mitral stenosis. He also had multiple moderate-risk factors including diabetes, hypertension, and systolic heart failure. Even though our patient had already been treated with anticoagulant, stability of oral anticoagulation therapy is essential to avoid thromboembolic as well as bleeding complications. For the majority of these patients, a target INR (international normalized ratio) of 2.5 is optimal [7]. Recent guidelines also recommend that in patients with AF who have ischemic stroke or systemic embolism during treatment with low-intensity anticoagulation (INR 2.0 to 3.0); it may be reasonable to raise the intensity of anticoagulation to a maximum target INR of 3.0 to 3.5.
Summary
We want to emphasize that AF, mitral valve stenosis and left ventricular systolic dysfunction in combination cause slow flow in the left atrium, causing a high risk for thrombus formation. The practitioner should be aware that in high risk patients, even though patients are treated with anticoagulant, the possibility of thrombus formation in the left atrium may cause a sudden change in symptoms. In this group of high risk patients, close clinical follow-up and supratherapeutic INR may be of benefit.
References







Figures at a glance

image   image   image     image   image
Figure 1   Figure 2   Figure 3   Figure 4   Figure 5   Figure 6
Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Recommended Conferences

  • 20th European Cardiology Congress
    October 16-18, 2017 Budapest, Hungary
  • 3rd Global Summit on Heart Diseases
    November 02-04, 2017 Bangkok, Thailand
  • 22nd World Cardiology Congress
    December 11-12, 2017 Rome, Italy

Article Usage

  • Total views: 11732
  • [From(publication date):
    March-2014 - Oct 18, 2017]
  • Breakdown by view type
  • HTML page views : 7940
  • PDF downloads :3792
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri, Food, Aqua and Veterinary Science Journals

Dr. Krish

[email protected]

1-702-714-7001 Extn: 9040

Clinical and Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemical Engineering and Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001 Extn: 9040

Earth & Environmental Sciences

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

General Science and Health care Journals

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics and Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001 Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Informatics Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Material Sciences Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Mathematics and Physics Journals

Jim Willison

[email protected]

1-702-714-7001 Extn: 9042

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001 Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

John Behannon

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001 Extn: 9042

 
© 2008-2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords