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A 71-year-old woman with a one-year history of dyspnea on exertion presented to the emergency department with worsening shortness of breath. Physical examination demonstrated rapid atrial fibrillation and a grade 4/6 holosystolic murmur of mitral-valve regurgitation. Transthoracic echocardiography revealed a thickened mitral valve with regurgitant flow and a round mass moving about randomly in the left atrium (Panel A and video clip). At surgery, a perfectly round mass the color of a partially ripe plum was found lying free in the left atrium (Panel B) and was removed from the atrial cavity. Gross examination of the specimen revealed a spherical mass 3.2 cm in diameter, which was subsequently confirmed to be a thrombus. There was also thrombus protruding from the left atrial appendage and thickened mitral-valve leaflets with rolled edges and fused commissures, findings consistent with the presence of rheumatic mitral-valve disease. A mitral-valve commissurotomy was performed, and the left atrial appendage was ligated.
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