The thrombus image in the huge left atrial appendage.

A 55 year-old woman presented to our cardiology clinic with shortness of breath. She had a history of mitral stenosis and chronic atrial fibrillation. The patient was treated with anticoagulant therapy. She reported that she had consumed 5 mg of warfarin daily for more than two years. On admission to the hospital, the patient’s international normalized ratio (INR) revealed an ineffective anticoagulation level (INR = 1.06). She was referred to the echo laboratory to assess left ventricular systolic functions and the quantification of mitral stenosis. Transthoracic echocardiography revealed pericardial effusion, moderate mitral stenosis, and a large left atrial appendage. The Doppler gradient was assessed using the apical window. The maximal and mean gradients were calculated: 12 mm Hg and 6 mm Hg, respectively. The mitral valve area was measured at 1.5 cm by the planimetric method.