Clinical and echocardiographic features of two large left atrial parietal thrombi.

A 62-year-old woman with severe mitral stenosis and two large parietal thrombi inside the left atrium is described. The patient was admitted to the hospital because of heart failure. Transthoracic and transesophageal echocardiography showed a severe calcific mitral stenosis and two large (56.9 and 46.2 mm in diameter) parietal thrombi inside the left atrium attached to the interatrial septum and associated with severe spontaneous echo contrast. This severe spontaneous echo contrast was detected in the left atrium and in the left atrial appendage. The patient was referred for cardiac surgery. The two large parietal thrombi were removed, and the valve was replaced with a Sorin-Bicarbon mitral valve prosthesis. Intraoperative transesophageal echocardiography after replacement of the mitral valve prosthesis and removal of the thrombotic mass showed absence of any spontaneous echo contrast in the left atrium and in the left atrial appendage. This report describes the diagnostic approach and successful surgical treatment of two very large parietal thrombi inside the left atrium associated with severe mitral stenosis and atrial fibrillation, which is a rare occurrence.

[Cardiogenic shock in acute myocardial infarct]. / Kardiogeni sok u akutnom infarktu miokarda.

Cardiogenic shock is the most important fatal complication of acute myocardial infarction (AMI). This syndrome may be considered as a severe form of left ventricular failure and the mortality rate is very high. According to the clinical classification, Killip class IV ranges from 60 to 95%, depending on authors. Shock occurs in about 15-20% of patients with AMI and accounts for at least 70% of the in-hospital deaths. During 1994, 168 patients with AMI were treated at the Intensive Care Unit of the Zagreb General Hospital, of which 14 (8.2%) developed cardiogenic shock. Ten patients experienced the first myocardial infarction, and 4 were admitted because of the second myocardial infarction, that time of anterior localization. Signs of cardiogenic shock were present in 8 (57.1%) patients already on admission. Three patients developed cardiogenic shock during the first 10 hours of hospitalization and further 3 patients during the initial 4 to 15 days of treatment. Older age prevailed. Eleven (78.5%) persons were older than 60 years of age. Eight patients demonstrated anterior infarction, 4 had inferior infarction and 2 non-Q-wave infraction. All patients had signs of left ventricular failure evidenced by pulmonary edema (Killip class IV) and later complicated by arrhythmia. Of the 14 patients who had AMI with the shock syndrome, 13 (92.8%) died; 5 (35.7%) patients during the first 2 hours, 3 (21.4%) within 24 hours of infarction, and 5 (35.7%) patients during the initial 4 to 25 days of treatment. Patients were treated conservatively, and only 3 patients received thrombolytic therapy, namely, streptokinase.