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Clinical Picture

Concentric circles in left atrium


Xiaojun Xie, Jiao Bai

Lancet 2018; 391: 2448 A 51-year-old woman, who had a history of rheumatic A
Department of Cardiovascular heart disease, was admitted to hospital with a recent
Surgery (X Xie MS) and onset of reduced level of consciousness and right-sided
Department of Radiology
weakness. Initial neurological examination was
(J Bai MS), Affiliated Hospital of
Southwest Medical University, consistent with a right-sided hemiplegia. A CT scan of
Luzhou, China her head confirmed infarction of the left basal ganglia
Correspondence to: and left paraventricular regions of the brain. Examination
Dr Xiaojun Xie, Department of of her cardiovascular system found her heart to be in
Cardiovascular Surgery, Affiliated
atrial fibrillation with a ventricular rate of 110 beats per
Hospital of Southwest Medical
University, Luzhou, 646000, min. A diastolic murmur was heard on auscultation at
China the apex. A non-contrast chest CT scan showed a 6 cm
xiexiaojun3315@163.com diameter, high attenuation circle in the left atrium
(figure). Further investigation using transthoracic
echocardiography (figure) revealed a mobile left atrial
mass with concentric circles around the periphery,
consistent with a free-floating thrombus; it also showed B
severe mitral stenosis with a dilated left atrium filled
with dense spontaneous echo contrast and no left atrial
appendage thrombus.
The woman, who was first diagnosed with rheumatic
heart disease 10 years ago, was taken to surgery, where
the free-floating mass was removed and the mitral valve
replaced. Subsequent pathological examination con­
firmed a giant thrombus with a smooth outer shell,
and an area below the surface containing multiple
haemorrhagic regions. The variable consistency of this
subsurface area may have been the cause of the
concentric circles seen on CT scan and transthoracic
echocardiography.
Left atrial ball thrombi almost always form in the
setting of mitral valve disease and are linked to high rates
of embolism. Prompt surgical removal is the recom­ C
mended and appropriate therapeutic intervention.
Contributors
We were responsible for writing and editing the manuscript. XX collected
the images. Written consent from the patient’s legal representative for
publication was obtained.

© 2018 Elsevier Ltd. All rights reserved.

Figure: Concentric circles in the left atrium


Non-contrast chest CT showing a 6 cm diameter high attenuation circle in the
left atrium (A). Transthoracic echocardiography showed a mobile, left atrial mass
with concentric circles around the periphery, consistent with a free-floating
thrombus. It also showed severe mitral stenosis with a dilated left atrium
(B and C).

2448 www.thelancet.com Vol 391 June 16, 2018