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A 73-year-old man was admitted to the emergency department with acuteonset orthopnea. He had a history of rheumatic mitral stenosis and permanent atrial fibrillation (AF), and he was taking warfarin. His prothrombin time (33.3 s) and international normalized ratio (2.83) were within therapeutic limits. Transthoracic echocardiograms revealed rheumatic mitral leaflets, gross pericardial effusion (Fig. 1), marked left atrial (LA) enlargement (15.6 × 8.3 cm), grade 4 spontaneous echo contrast (SEC) (Fig. 2), and mild mitral insuff iciency (Fig. 3). The mitral valve area was 0.8 cm, and the LA volume was 1,966 mL. A transthoracic echocardiogram showed dense SEC flowing through the stenotic mitral valve and disappearing immediately after entering the left ventricle. Images in Cardiovascular Medicine

Spontaneous Echo Contrast in a 73-Year-Old Man with Mitral Stenosis and a Giant Left Atrium