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.