A big pinball-like thrombus in the heart

Excerpt

A 65-year-old man presented to our hospital complaining of exertional dyspnea. Previously, he had a history of atrial fibrillation for 10 years and accepted oral warfarin therapy with INR range between 2.0 and 2.5. Six months before, he replaced warfarin with dabigatran (110 mg bid) for hemoptysis. On admission, two-dimensional echocardiogram revealed a big “ball” in the enlarged left atrium (LA) (80 × 57 mm, Fig. 1a). During each cardiac cycle, the “ball” moved toward the mitral valve with the diastolic blood flow, then was bounced by the closing valve (just like a pinball game, supplementary video material). Cardiac surgery was conducted to remove the “ball” which affected heart function greatly. After surgery, it was confirmed as a big thrombus of multiple layers with a diameter of 45 mm (Fig. 1b). This case raises concern whether the “one dose fits all” prescription of anticoagulant could achieve adequate anticoagulation activity because blood concentration might potentially vary among patients.

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