Case Report:
A 49-year-old man presented to the emergency department with right-sided weakness and aphasia. He had no history of hypertension, diabetes mellitus, and dyslipidemia. Since six months, he presented a worsening fatigue and exertional dyspnea.
On admission, the physical examination revealed broca’s aphasia, right hemiparesis and facial weakness. His blood pressure was 90/60 mm Hg, heart rate was 120 beats per minute, respiratory rate was 30 breaths per minute, and temperature was 37.2°C. General appearance was cachectic (height 170 cm, weight 45 kg). The patient presented with a NYHA III dyspnea. On examination, the patient had a poor hygiene of teeth, a right parasternal heave, a loud S1, an opening snap, and a high-pitched diastolic rumble at the apex.
Twelve-lead electrocardiography indicated sinusal rhythm, but 24-Hour Holter monitoring revealed a paroxysmal atrial fibrillation. Laboratory tests revealed high levels of high-sensitivity troponin I (450 ng/L), and D-dimer (3000 µg/L). Chest radiography revealed an increase in the size of the cardiac shadow, convexity of the left atrial appendage just below the main pulmonary artery, and double density sign.
Computed Tomography Scan of the brain diagnosed a large ischemic infarction involving the territory of the left middle cerebral artery.
Transthoracic echocardiography showed a hockey-stick shape and thickened anterior mitral valve leaflet, restricted posterior mitral valve leaflet, fusion of chordal and calcification on parasternal long axis view, and a large free-floating ball-valve thrombus (4.24 cm in diameter) with anti-clockwise spinning movement in the dilated atrium (60 mm) (Figures 1 and 2). Short axis view showed a several mitral stenosis with a valve area of 0.9 cm2 (Figure 3). Apical four chamber view showed the ball thrombus which partially obstructed the mitral valve intermittently (Figure 4). The left ventricular ejection fraction was normal (60% Biplane Simpson), with normal left ventricular filling pressure and pulmonary artery systolic pressure (25 mmHg).
Final diagnosis was rheumatic mitral valvular stenosis disease with paroxysmal atrial fibrillation complicated of ball thrombus and an ischemic stroke.
After initial stabilization, the patient was treated with Fluindione and physical therapy which gradually improved his general condition. The replacement of the mitral valve with removal of the ball-valve thrombus will be indicate 6 months later.