From a purple digit to left atrial appendage thrombus: the critical role of point-of-care transesophageal echocardiography in the emergency department: a case report

Digital ischemia may be the initial manifestation of Left Atrial Appendage (LAA) thrombosis, even in the absence of atrial fibrillation. We report the case of a 79-year-old woman presenting to the Emergency Department (ED) with transient right-hand hyposthenia, paresthesia, and cyanosis ("purple digit"). The patient had known mitral stenosis and regurgitation but no history of atrial fibrillation. Although Transthoracic Echocardiography (TTE) identified MS and atrial dilatation, it failed to visualize the embolic source, a focused bedside Transesophageal Echocardiography (TEE) performed by emergency physicians revealed a large thrombus within the LAA. This finding identified the cardioembolic source for both her digital and concomitant Chronic cerebral ischemic events finding in brain computed tomography. Anticoagulation was promptly started after TEE performed leading to clinical improvement. This case underscores that in patients with structural heart disease, early TEE in the ED is essential to detect occult embolic sources missed by TTE and to guide appropriate stroke-prevention therapy.