We herein describe a case and provide images of a bioprosthetic mitral valve thrombosis and a huge left atrial appendage thrombus occurring during atrial fibrillation 12 years after initial heart surgery. The patient was treated conservatively with oral anti-coagulation because he was a high surgical risk with complete resolution of the thrombosis after 2 months of therapy. This case suggests that in a high surgical risk patient, effective oral anticoagulation might be a good alternative to surgery.

An 86-year-old man with end-stage renal disease on hemodialysis with an arteriovenous fistula in his left upper extremity presented to his hemodialysis session with thrombosis of his arteriovenous fistula. The patient underwent surgical thrombectomy. The patient later showed evidence of peripheral embolization and livedo reticularis. Transthoracic and transesophageal echocardiograms revealed a large thrombus (5x2 cm) in the left atrium prolapsing to the right atrium via a patent foramen ovale and another thrombus (white arrow) adherent to the apical wall of the right ventricle. The thrombus in the left atrium was intermittently crossing the mitral valve and entering the left ventricle.