Incidental finding of a filamentous mass in the left atrium in a patient investigated for endocarditis.

Hammersley D, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-219280 Description A previously fit and well middle-aged woman presented with a 24-hour history of deteriorating breathlessness and rigors. The patient showed signs of acute respiratory distress. She was febrile, tachycardic and had a loud pansystolic murmur at the cardiac apex. A chest radiograph showed right lower zone consolidation, and an ECG showed sinus tachycardia. Blood tests showed raised inflammatory markers with white cell count of 11.8×10/L (normal range 4–10×10/L) and C reactive protein 56 mg/L (normal range 0–10 mg/L). A transthoracic echocardiogram identified severe mitral regurgitation secondary to posterior mitral valve leaflet prolapse with a hyperdynamic left ventricle. Peripheral blood cultures were negative. The patient was treated for community-acquired pneumonia and presumed endocarditis. A transoesophageal echocardiogram (TOE) confirmed severe mitral regurgitation secondary to a flail posterior mitral valve scallop (P2) with ruptured primary and secondary chords. There was also a posterior leaflet calcium spur and a vegetation. In addition, the TOE demonstrated a long, filamentous, mobile structure arising from the left atrial wall where the anteriorly directed jet of mitral regurgitation struck the left atrium (figure 1 and online supplementary video). The patient underwent a mitral valve repair with a 26 mm annuloplasty ring, insertion of Gore-Tex neochords and removal of the filamentous mass. This was fibrous and was not infected (figure 2).