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Background: Left atrial (LA) thrombus is not rare in patients with mitral valve stenosis, but in patients with nonvalvular atrial fibrillation on anticoagulation, the formation of a "ball thrombus" in the LA is uncommon.

Case: A 73-year-old man with nonvalvular atrial fibrillation on eliquis presented with frequent syncope and slurred speech. .The appearance of the infarcts on brain MRI and involvement of different vascular territories suggests embolic phenomena as the cause. On transthoracic echo a large, highly mobile echo density in the left atrium was noted. Transesophageal echo revealed smoke in the left atrium and the left atrial appendage. A large round mobile echo density mass measuring 4.7 cm X 3.6 cm was seen in left atrium with no attachment to left atrium. A mobile round density measuring 0.7x0.7 cm was seen on the right coronary cusp. Absence of perfusion, no enhancement, and high signal intensity on …