thrombus-in-transit entrapped in a partially ligated left atrial appendage

a 54-year-old man referred to our center with barlow’s disease and severe mitral regurgitation. he had atrial fibrillation (af) rhythm, with a mildly enlarged left atrium (la). transesophageal echocardiography (tee) showed no clot in the la and la appendage; there was only mild spontaneous echo contrast in the la appendage. the patient underwent mitral valve repair and the maze operation, during which the la appendage was ligated with the double suture technique. he was discharged from the hospital in good condition and in sinus rhythm. he was recommended warfarin and pt control. one month later, he returned with the complaint of vision loss twice in the left eye each time for a few seconds. the af rhythm had returned.tee demonstrated a fresh and mobile thrombus entrapped in the la appendage with a small portion in the la (figures 1 and 2). laboratory tests showed therapeutic international normalized ratio (inr). the patient refused re- operation.  plavix was added to his medication, and he was discharged.