Coincidence of Free-Floating Thrombus in the Aortic Arch, Severe Mitral Stenosis, and Left Atrial Appendage Clot

We describe the surgical management of a free-floating thrombus in the aortic arch in a patient with severe mitral stenosis, a left atrial appendage (LAA) clot, and an iliac artery thrombus. A 60-year-old woman complaining of dyspnea and pain in her right leg was referred to our multidisciplinary clinic. After a brief history was taken, an electrocardiography evaluation showed atrial fibrillation. Color Doppler sonography of the lower limb arteries showed decreased blood flow in distal branches of the internal iliac artery of the right leg. Transthoracic and transesophageal echocardiography evaluations revealed severe mitral stenosis, a large LAA clot, and a large mobile mass (2 × 1.5 × 1.5 cm) in the distal aortic arch. Additional investigations with computed tomographic angiography revealed that the thrombus extended from the aortic arch to the subclavian artery. Another bulky thrombus in the right iliac artery was also found. Given this complicated medical situation, emergency cardiac surgery was performed, and the clot was removed. The stenotic mitral valve was replaced with a prosthetic valve, The LAA was closed after clot removal, and the bulky thrombus was extracted from the right iliac artery. Transesophageal echocardiographic data were obtained postoperatively, and the patient's course in the intensive care unit was favorable. She was discharged from the hospital in good condition on warfarin, digoxin, aspirin, and metoprolol.