Ring-shaped thrombus in left atrial appendage: a contraindication for valvotomy.

To cite: Mahla H, Bhat P, Bhairappa S, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013201108 DESCRIPTION 45-year-old woman presented with rheumatic heart disease-severe mitral stenosis. The patient had atrial fibrillation with New York Heart Association class II status. She was on diuretics, rate controlling drugs and warfarin 2 mg/day. International normalised ratio (INR) value was 1.8. Transthoracic echocardiogram revealed no evidence of thrombus in left atrium or appendage. As valve morphology was suitable for valvotomy, warfarin was stopped 5 days before planned date of valvotomy and injectable heparin started. Transesophageal echocardiogram was performed 3 days before planned valvotomy to rule out any thrombus. It revealed grade 4+spontaneous echocontrast (intense echodensity with very slow swirling movements of blood within left atrium and equal density in appendage) with ringshaped thrombus in left atrial appendage (figures 1 and 2; videos 1, 2, 3). Thrombus was echodense in periphery and echolucent in centre. This