Case 21 — Subsequent Examinations

Two Days After Discharge

Clinically better. Echo: persistent spontaneous contrast in LA. PT 9.7 sec (normal). Warfarin increased to 0.75 mg PO SID. Heparin discontinued.

Five Days After Discharge

Echo: persistent spontaneous contrast. PT 13.4 sec (longer but still normal). Continue current warfarin dose; retest in a couple of days.

Ten Days After Discharge

Echo: a very large clot in the left auricle. PT 98 seconds (severely prolonged). The clot will likely break free and cause sudden death. Warfarin stopped since it has not effectively prevented thrombus formation despite severely prolonging PT.

Right parasternal short-axis view showing a large thrombus (arrowheads) in the left auricle that formed despite warfarin therapy. AO — aorta; LA — left atrium.
Large thrombus (arrowheads) in the left auricle despite warfarin therapy. AO; LA.

Two and a Half Weeks After Discharge

PT 11.6 sec (normal). LA thrombus remains. Mild pericardial and pleural effusion. Pleural effusion likely from CHF. Lasix increased to 12.5 mg PO BID. Aspirin 81 mg PO q3d started.

Three and a Half Weeks After Discharge

Weight loss, lethargy, poor appetite — possibly from aspirin. Persistent spontaneous contrast and LA thrombus. Pleurocentesis: 50 ml pink/chylous effusion. Owner took Freckles home; aspirin stopped. Three days later: Freckles rebounded — eating, drinking, very active.

Four and a Half Weeks After Discharge

Eating well, more active, but increased respiratory effort. Thoracocentesis: 220 ml chylous fluid. LA thrombus unchanged.

Seven Weeks After Discharge

On atenolol 6.25 mg BID, enalapril 1.25 mg SID, Lasix 12.5 mg BID. Slightly increased respiratory effort. LA thrombus unchanged but appears mobile. Pleurocentesis: 110 ml serosanguinous fluid. Lasix increased to 18.75 mg BID.

Ten Weeks After Discharge

No thrombus present in LA today. No signs of thromboembolism. 140 ml pleural fluid removed.

Echocardiogram at ten weeks post-discharge showing the left atrium without the previously seen thrombus.
Ten weeks post-discharge: no LA thrombus visualized.

Eleven Weeks After Discharge

Dehydrated, not eating well. Lasix discontinued for 2 days; Freckles ate well. New thrombus visualized in LA. Severe pleural effusion: 175 ml chylous fluid removed. Hypokalemia (K 2.8); started Tumil-K. Mild azotemia unchanged.

Echocardiogram at eleven weeks showing a new left atrial thrombus.
Eleven weeks: new LA thrombus.

Video of dense, swirling spontaneous contrast in the left atrium and a thrombus in the left auricle from a different cat

Twelve Weeks After Discharge

Tachypneic, depressed, cyanotic MM, cachectic. HR 160 irregularly irregular. 220 ml chylous effusion removed. Improved after drainage. K 3.6 (low normal).

Thirteen Weeks After Discharge

Lasix increased to 18.75 mg BID again. Doing well at home. Eupneic. 105 ml chylous effusion drained. LA thrombus large and mobile.

Fourteen Weeks After Discharge

Weekly thoracocentesis. LA thrombus appears subjectively larger. 140 ml chylous effusion removed.

Fifteen Weeks After Discharge

HR 150, irregularly irregular. Very thin. 160 ml chylous effusion removed. LA thrombus unchanged.

Sixteen Weeks After Discharge

Phone conversation: Freckles was doing well. The owner went to the store and when she came home he was dead, lying peacefully in the hallway (sudden death). The owner buried Freckles in the back yard.

Summary

Freckles lived for four months with severe cardiac disease and a large left atrial thrombus that came and went. No one expected him to live this long, but he, his owner, and Dr. Adin persevered. His outcome should in no way be used to predict the outcome of any other cat with the same disease processes. Many cats with saddle thromboembolism die soon after, and almost all cats with a large left atrial thrombus do poorly. Freckles was a “miracle” cat who defied the odds.

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