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J Cardiovasc Med (Hagerstown). 2013 Mar 13. [Epub ahead of print]

The left atrial septal pouch as a possible location for thrombus formation.

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1
aBrugmann UH Brussels, Cardiology bBrugmann UH Brussels, Cardiac Surgery cJules Bordet Institute Brussels, Oncology, Brussels, Belgium.

Abstract

The left atrial septal pouch was described in 2010 by Krishnan and Salazar as a potential source of embolism. It is formed by the caudal fusion of the area of overlap of the septum primum and the septum secundum, leaving a cranial opening towards the left atrium. The potential for thrombus formation inside this pouch remains debatable. An 82-year-old woman was admitted to our institution for syncope. Several abnormal findings were noted: an atrial fibrillation and a systolic murmur. The patient was initiated on oral anticoagulation. A cranial computed tomographic (CT) scan ruled out a major stroke. Transoesophageal echocardiography showed a stenotic bicuspid aortic valve, important ascending aorta dilation and a mobile isoechoic structure arising from a typical left atrial septal pouch. The three-dimensional images revealed a crescent-shaped mass, significantly larger than the two-dimensional images had anticipated. In the setting of atrial fibrillation, a thrombus was highly probable. We noted the presence of spontaneous contrast in the left atrium. The left atrial appendage was free of echoes. The control transoesophageal echocardiogram before surgery noted the disappearance of the mass under anticoagulation without clinical signs of embolism. She underwent a successful Bentall procedure. The images presented here indirectly confirm the formation of thrombus inside the left atrial septal pouch in the setting of atrial fibrillation. They also highlight the role of three-dimensional imaging in the evaluation of intracardiac masses.

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