A 49-year-old male presented to hospital with symptoms of acute cerebral infarction and pulmonary embolism who underwent transcatheter closure of atrial septal defect a year ago. Transthoracic echocardiography showed a 13×9 mm hypoechoic mass attached to the left-atrial side of the device, which was suspected to be neoplasm or thrombus. The patient was indicated for surgery after multidisciplinary discussion due to ineffective medical therapy and typical stroke and pulmonary embolism symptoms. Three-dimensional transesophageal echocardiography (3D-TEE) revealed left-atrial vegetation (21×16 mm) and right-atrial vegetation (8×6 mm) attached to the device, which were confirmed as thrombus by surgical separation and laboratory examination. This case highlights the importance of 3D-TEE and a multidisciplinary team in the diagnosis and therapy of device-related thrombus.

A 50-year-old female presented with a history of fatigue after activities. Transthoracic echocardiography showed a 2.8 cm dilatation at the ostium of the left coronary artery and a 7.1×7.4 cm cyst-like aneurysm at the upper back of the left atrium, interlinking an anomalous fistula from the left coronary artery to the right atrial appendage, accompanied by moderate mitral and tricuspid regurgitation. Cardiac 3D-computed tomography identified the diagnosis of ruptured aortic sinus aneurysm (RASA) and a giant left coronary artery aneurysm fistula to the right atrium. Transesophageal echocardiogram and surgical vision confirmed these findings. Surgeries including RASA repair, coronary artery bypass grafting, and mitral and tricuspid valvuloplasty were then performed. Procedures proceeded successfully, the patient was fully recovered and discharged home.