Giant atrium, giant clot: need for anticoagulation

Description

We present a patient with medical history of atrial fibrillation, rheumatic mitral valve stenosis and ulcerative colitis who came to the emergency room with onset of bilateral lower extremity pain 2 hours prior to presentation. On examination, feet were pale, cold and pulses were absent. Patient used to be on warfarin for atrial fibrillation which was discontinued 1 month ago by his primary care physician due to recurrent bleeding. Atrial fibrillation with controlled ventricular response was seen on ECG. Emergent arterial Doppler revealed occlusion of the bilateral calf arteries at the level of the tibioperoneal trunk. Patient underwent emergent bilateral right and left groin exploration with bilateral embolectomy and thromboembolectomy. Restoration of flow with no haemodynamically significant atheromatous changes was confirmed by repeat Doppler. Echocardiography revealed severely dilated left atrium measuring 10 cm x 7 cm with large left atrial thrombi (figure 1, online) and severe mitral valve stenosis (mean gradient...

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