Two large thrombi were discovered moving freely within the left atrium of a 45-year-old woman presenting with breathlessness, swelling, and recent stroke. Echocardiography revealed severe mitral stenosis and pulmonary arterial hypertension from rheumatic heart disease, as well as the two thrombi measuring 23x16mm and 24x18mm. The patient underwent mitral valve replacement and removal of the thrombi. Ball valve thrombi are rare occurrences where thrombi detach entirely from the atrium walls and move freely due to excess narrowing of the blood flow pathway. This case of two large moving ball valve thrombi in the left atrium without prior embolism is exceptionally rare.

1. TWO MOVING OBJECTS IN LEFT
ATRIUM
Dr Anup Pusate*
Dr Sunil Washimkar**
Dr Pritesh Pawar*
Dr Rohan Parikh*
Dr Amey Bheedkar*
Dr Pradeep Deshmukh***
Dr Mukund Deshpande****
Cardiology Dept, GMC-SSH Nagpur
* Senior Resident; **Assistant Professor; ***Associate Professor; ****Professor
& HOD
Echo CME Cases- Cardiac Masses

2. CASE DETAILS
• A 45 years old lady presented with complaints of:
• Breathlessness (NYHA class II) since 8 years
• PND since 15days
• Stroke with hemiparesis of left side of body since 7 days

3. Examination
• Pulse- 98/min, regular; BP- 94/60 mmHg
• S1 loud, Mid diastolic murmur grade 3/6 at apex present
• ECG- Sinus tacchycardia, right axis deviation , left atrial
enlargement
• 2D-Echo and TEE: Rheumatic heart disease, Severe Mitral
Stenosis, Severe PAH and two moving thrombi in Left
atrium of 23x16 and 24x18mm.
• Treatment: Mitral Valve Replacement with Thrombus
removal done

5. Welch diagnostic criteria for Ball Valve
Thrombus
1. Entire absence of attachment of thrombus with
consequent free motility
2. Imprisonment in consequence of an excess in
diameter of first narrowing in the circulatory
passage ahead of it
Reference: Welch W. thrombosis In. Allbutts System of Medicine. Macmillon;
London 1899.vol 6, p.720.

6. • Incidence:
– LA thrombus is present in mitral stenosis in 17%. Atrial
fibrillation doubles the risk.
– In a study of 490 patients in Pondichery with RHD and
mitral stenosis, 169 were found to have thrombus in LA or
LAA but none have ball valve thrombus.
• Conclusion:
– though literature has mentioned several reports of Ball
valve thrombus but its occurrence is rare and that too of
two moving ball valve thrombus without embolisation is
very rare .