A ping-pong ball in left atrium.

Accepted 18 December 2017 DesCripTion Rheumatic heart disease (RHD) is much prevalent in low/middle-income country like India with the prevalence ranging from 0.2 to 1.1/1000 for RHD and from 0.0007 to 0.2/1000 for rheumatic fever. Factors that precipitate the formation of clot are atrial fibrillation (AF) rhythm, left atrial (LA) size, duration of symptoms, advanced age and severity of mitral stenosis (MS). The prevalence of LA clot in patients with MS is 26% in the AF group and 13.5% in the normal sinus rhythm group. The risk of thromboembolism is 9–14% of patients suffering from RHD. 5 Anticoagulation (vitamin K antagonist or heparin) is indicated in patients with MS with (1) AF (paroxysmal, persistent or permanent) or (2) prior embolic event or (3) a LA thrombus. We present a case of a 30-year-old man, a known case of RHD who had balloon mitral valvotomy (BMV) 10 years ago. He presented with increase in frequency of palpitation and dyspnoea on exertion (New York Heart Association (NYHA) class III) for the last 5 months. The patient was in sinus rhythm and was receiving beta-blocker and diuretic. His transthoracic (TT) 2D echocardiography (ECHO) revealed moderate mitral valve restenosis with mitral valve area reduced to 1.1 cm (planimetry method) and 1.2 cm (pressure half time method). The peak and mean gradient across the mitral valve were 11 and 6 mm Hg, respectively. He also had trivial mitral regurgitation and left ventricular ejection fraction was 65%. LA size was 5.2×7.2 cm. Both TT and transoesophageal (TOE) ECHO revealed a large freely mobile LA clot measuring 2.2 cm in diameter. The large LA clot was seen falling intermittently into the mitral apparatus to be hit back again by the mitral leaflet (figure 1, video 1, video 2). The large thrombus in LA gave appearance similar to the ping-pong ball moving to and fro in the mitral apparatus. Patient was not on any anticoagulation or antiplatelets at the time of diagnosis of LA clot. Patient was started on oral anticoagulation (warfarin 2 mg once a day and gradually increased to achieve Figure 1 Transoesophageal echocardiography at mid oesophagus showing four-chamber view with 5.2×7.2 cm large left atrial clot.