Brain embolism, left atrial thrombi and cardiosurgery

Patients with embolization into the brain and mobile thrombus in the left atrium (LA) are in the danger of recurrent embolization. A patient with the history of recent cerebral vascular accident (CVA) would be at higher risk of cerebral complications due to cardiopulmonary bypass and this risk may be as high as that of re-embolization. We present a case of a 41-year old man with an acute ischemic focus (3 x 3 cm) in the temporoparietal lobe verified by computer tomography (CT). Transthoracic echocardiography showed severe aortic insufficiency, low ejection fraction of dilatated left ventricle (LV). Transesophageal echocardiography showed a mobile thrombus (2.2 x 1.1 cm) in LA. The cardiovascular surgeon consultant did not recommend urgent operation. Instead, the patient was treated by low molecular heparin. CT of the brain after 10 days of treatment was normal. Patient underwent a successful aortic valve replacement. At the time of surgery there was no thrombus in the LA. Subsequently, the patient recovered normally with no neurologic sequelae. This case illustrates the difficulty arising from the consideration of the relative risks of acute surgery vs conservative management in patient with recent CVA and a large mobile thrombus in LA.