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A 73-year-old man was admitted to the emergency department with acute-onset orthopnea. He had a history of rheumatic mitral stenosis and permanent atrial fibrillation (AF), and he was taking warfarin. His prothrombin time (33.3 s) and international normalized ratio (2.83) were within therapeutic limits. Transthoracic echocardiograms revealed rheumatic mitral leaflets, gross pericardial effusion (Fig. 1), marked left atrial (LA) enlargement (15.6 × 8.3 cm), grade 4 spontaneous echo contrast (SEC) (Fig. 2), and mild mitral insufficiency (Fig. 3). The mitral valve area was 0.8 cm2, and the LA volume was 1,966 mL. A transthoracic echocardiogram showed dense SEC flowing through the stenotic mitral valve and disappearing immediately after entering the left ventricle.

Fig. 1. Transthoracic echocardiogram (parasternal long-axis view) shows rheumatic mitral leaflets, gross pericardial effusion, dense left atrial spontaneous echo contrast, and thickened pericardium. / Supplemental motion image is available for Figure 1.Fig. 1. Transthoracic echocardiogram (parasternal long-axis view) shows rheumatic mitral leaflets, gross pericardial effusion, dense left atrial spontaneous echo contrast, and thickened pericardium. / Supplemental motion image is available for Figure 1.Fig. 1. Transthoracic echocardiogram (parasternal long-axis view) shows rheumatic mitral leaflets, gross pericardial effusion, dense left atrial spontaneous echo contrast, and thickened pericardium. / Supplemental motion image is available for Figure 1.
Fig. 1 Transthoracic echocardiogram (parasternal long-axis view) shows rheumatic mitral leaflets, gross pericardial effusion, dense left atrial spontaneous echo contrast, and thickened pericardium. Supplemental motion image is available for Figure 1.

Citation: Texas Heart Institute Journal 44, 6; 10.14503/THIJ-15-5171

Fig. 2. Transthoracic echocardiogram (apical 4-chamber view) shows severe left atrial enlargement and flow of spontaneous echo contrast through the mitral valve. / Supplemental motion image is available for Figure 2.Fig. 2. Transthoracic echocardiogram (apical 4-chamber view) shows severe left atrial enlargement and flow of spontaneous echo contrast through the mitral valve. / Supplemental motion image is available for Figure 2.Fig. 2. Transthoracic echocardiogram (apical 4-chamber view) shows severe left atrial enlargement and flow of spontaneous echo contrast through the mitral valve. / Supplemental motion image is available for Figure 2.
Fig. 2 Transthoracic echocardiogram (apical 4-chamber view) shows severe left atrial enlargement and flow of spontaneous echo contrast through the mitral valve. Supplemental motion image is available for Figure 2.

Citation: Texas Heart Institute Journal 44, 6; 10.14503/THIJ-15-5171

Fig. 3. Transthoracic echocardiogram of the left atrium (apical 4-chamber view in color-flow Doppler mode) shows mild mitral insufficiency.Fig. 3. Transthoracic echocardiogram of the left atrium (apical 4-chamber view in color-flow Doppler mode) shows mild mitral insufficiency.Fig. 3. Transthoracic echocardiogram of the left atrium (apical 4-chamber view in color-flow Doppler mode) shows mild mitral insufficiency.
Fig. 3 Transthoracic echocardiogram of the left atrium (apical 4-chamber view in color-flow Doppler mode) shows mild mitral insufficiency.

Citation: Texas Heart Institute Journal 44, 6; 10.14503/THIJ-15-5171

Comment

Spontaneous echo contrast, an echogenic swirling motion of blood, is thought to be related to a reversible, protein-mediated aggregation of erythrocytes in conditions of blood stasis or low-velocity blood flow.1 The presence of SEC in the LA and LA appendage is an independent predictor of thromboembolic risk in patients with mitral stenosis.2 Anticoagulation is indicated when they also have new-onset or paroxysmal AF. If patients are in sinus rhythm, oral anticoagulation should be considered when transesophageal echocardiograms show dense SEC or an enlarged LA.3 However, SEC seems to be independent of activation of the clotting system.4 In patients with nonvalvular AF, anticoagulation therapy has not prevented SEC, and—despite continued oral anticoagulation—these patients have an increased risk of cerebral embolism or death.5,6

Our patient was taking effective anticoagulant medication and had dense SEC in the LA, with flow through the mitral valve. The disappearance of the SEC as soon as it passed through that valve appears to be associated with decreased velocity of blood flow in the LA. Nevertheless, in patients with mitral stenosis and dense left atrial SEC, anticoagulation should be considered, even if the patient is in sinus rhythm.

References

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Fig. 1
Fig. 1

Transthoracic echocardiogram (parasternal long-axis view) shows rheumatic mitral leaflets, gross pericardial effusion, dense left atrial spontaneous echo contrast, and thickened pericardium.

Supplemental motion image is available for Figure 1.

Fig. 2
Fig. 2

Transthoracic echocardiogram (apical 4-chamber view) shows severe left atrial enlargement and flow of spontaneous echo contrast through the mitral valve.

Supplemental motion image is available for Figure 2.

Fig. 3
Fig. 3

Transthoracic echocardiogram of the left atrium (apical 4-chamber view in color-flow Doppler mode) shows mild mitral insufficiency.

Contributor Notes

Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute, 6624 Fannin St., Suite 2480, Houston, TX 77030

From: Department of Cardiology (Drs. Amasyali and Kilit), Faculty of Medicine, Dumlupinar University; and Department of Cardiology (Dr. Astarcioglu), Kutahya Evliya Celebi Training and Research Hospital; 43050 Kutahya, Turkey

Address for reprints: Celal Kilit, MD, Dumlupinar University, Kutahya Evliya Celebi Training and Research Hospital, Evliya Celebi Quarter, Okmeydani St., 43050 Kutahya, Turkey, E-mail: ckilit@hotmail.com