Key result
Left atrial septal pouch thrombus in new-onset AF causes blue toe syndrome requiring amputation and anticoagulation.
Why the study?
Establishing the etiology of blue toe syndrome is vital to treat the underlying cause, and the authors describe the first case arising from a left atrial septal pouch thrombus on a background of new-onset AF.
Case Report (n=1)
No
Left atrial septal pouches can serve as a nidus for thrombus formation and should be considered as a potential source of peripheral emboli in patients with blue toe syndrome.
Blue toe syndrome may prompt septal pouch imaging in new AF; single case leaves open need for systematic evaluation.
BACKGROUND: Left atrial septal pouches (LASPs) are a relatively newly described but common anatomical cardiac variant thought to be associated with atrial fibrillation (AF) and cardio-embolic stroke. Blue toe syndrome (BTS) describes ischemic changes in the toes due to microembolisation of the digital arteries. Establishing the etiology of BTS is vital so that the underlying cause can be treated. Here we describe the first case of BTS arising due to emboli from LASP thrombus arising on a background of new-onset AF. CASE PRESENTATION: A 65-year-old man presented with a two-day history of progressive painful swelling and bluish-purple discoloration of the second and fourth toes of his left foot and new-onset AF. Tests for hypercoagulability disorders were negative. Duplex ultrasound and CT angiography excluded deep venous thrombosis and an absence of embolus, thrombus, or occlusion in the arterial tree in the lower extremities bilaterally, so BTS was diagnosed. While transthoracic echocardiography and chest CT initially showed no cardiac abnormalities or mural thrombus, subsequent transesophageal echocardiography revealed a LASP with an associated pedunculated thrombus. The affected toes were amputated due to wet gangrene, but the patient recovered well with thrombus resolution after anticoagulation. CONCLUSION: The presence of a LASP in the absence of any other identifiable cause of BTS should trigger careful investigation of the interatrial septum, preferably using a multimodality imaging approach. The possibility that LASPs may not merely be an innocent bystander but a causative mechanism for peripheral ischemia must be considered.
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Pradhan et al. (2020) conducted a case report in Blue toe syndrome (n=1). Left atrial septal pouch thrombus was evaluated on Clinical recovery and thrombus resolution. A left atrial septal pouch thrombus in the setting of new-onset atrial fibrillation was identified as a novel cause of blue toe syndrome, which resolved after toe amputation and anticoagulation.
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