Clinics in Medical Education

Case by Case Insights into Advanced Echocardiographic Diagnostics

David Benavides Zora, MD, Sumeeta Kapoor, MD, Yifan Bu, MD, Maurizio Bottiroli, MD

Published April 18, 2025 | Clinics in Medical Education 

Issue 6 | Volume 1 | April 2025

A 79-year-old male with a history of atrial fibrillation on warfarin, COPD, and GERD presented with acute limb ischemia of the left lower extremity (LLE). He underwent LLE cutdown, thrombectomy, percutaneous transluminal angioplasty (PTA), and four-compartment fasciotomies. A large left atrial thrombus was identified in the extensive workup. The patient subsequently presented for resection of a left atrial mass.

Intraoperative Findings:

Echocardiogram (TEE) – Initial Assessment:

  • Severe biatrial enlargement with normal biventricular size and preserved function (EF: 55%).
  • No significant valvular regurgitation or stenosis.
  • Large (3 × 2 cm) left atrial mass attached to the interatrial septum, appearing hyperechoic with two hypoechoic areas in its center.
  • No obstruction of the mitral valve; normal gradients.
  • No abnormalities in the aorta, no patent foramen ovale (PFO), no effusion, and no left atrial appendage (LAA) thrombus.

Unexpected Intraoperative TEE Findings: 

  • Just minutes before incision, repeat TEE (2D and 3D) no longer showed evidence of the left atrial mass.
  • No mass detected in the mitral valve or left ventricle.
  • Detailed inspection of the aortic valve, ascending aorta, distal aortic arch, and descending thoracic aorta showed no evidence of the mass.
  • Carotid ultrasound also did not reveal any mass.
  • The patient was transferred intubated to the ICU and subsequently underwent CTA.

CTA Findings:

  • Superior Mesenteric Artery: Non-occlusive thrombus located ~4.5 cm from the takeoff.
  • Right Lower Extremity: Occlusive thrombus extending from the right popliteal artery to the anterior and posterior tibial artery bifurcation.
  • Left Lower Extremity: Occlusive thrombus in the left external iliac artery with minimal flow in the distal deep femoral artery. No opacification of the left lower extremity distal to the popliteal artery, possibly due to contrast bolus timing and/or occlusive thrombus.

Figure 1

Left Atrial Mass

Clinical Considerations:

  • The left atrial thrombus has the potential to embolize to the femoral, popliteal, brachial, mesenteric, and renal arteries.

  • It’s vital to rule out brain, gut, and renal ischemia immediately.

  • Cardiac emboli account for approximately one-third of all ischemic stroke cases.

Click here to view the TEE images and findings