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Updated: Sep 8, 2025

Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Left Atrial Thrombus in Rheumatic Mitral Stenosis: A Case of Therapeutic International Normalized Ratio Failure
Muhammad Salman Sabri1, Carly Weber2, Yanis Belkadi3
1Department of Internal Medicine, Jefferson Abington Hospital, Abington, Pennsylvania, USA.
Background:
Atrial fibrillation or flutter in rheumatic mitral stenosis (MS) increases left atrial appendage (LAA) thrombus risk despite therapeutic anticoagulation.
Case Summary:
A 72-year-old woman on warfarin with moderate MS and atrial flutter presented with dyspnea. Transesophageal echocardiogram (TEE) showed a large LAA thrombus despite an international normalized ratio >2.5. Cardioversion was deferred, and the international normalized ratio target was raised to a range of 2.5 to 3.5.
Take-Home Messages:
While cardioversion can be considered in patients with uninterrupted anticoagulation without TEE, those with rheumatic MS are at high risk of LAA and LA thrombus and should undergo TEE before the procedure. Further research is needed to explore whether LAA thrombus warrants surgical intervention for rheumatic MS.
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