Tear, Tumor, or Thrombus
A 48-year-old woman who weighed 176 kg and had known hypertension presented with acute chest pain radiating to the back and numbness of the left arm. On admission, the left arm was cold and the left radial pulse was significantly weaker than the right. ECG showed inferolateral ST-segment elevation suggestive of acute myocardial infarction. Chest x-ray suggested possible widening of the mediastinum. The possibility of acute aortic dissection complicated by myocardial infarction was considered and further investigated. Computed tomographic (CT) scan of the chest could not be done because the weight limit for the scan table was 150 kg, and the aperture of the scanner was too small for the patient. Hence, a transesophageal echocardiogram was performed, which showed echo-dense mobile structures attached to the aortic wall in the ascending aorta 2 to 3 cm above the aortic valve with the suggestion of a possible tear in the intima (Movies I and II). There was mild left ventricular hypertrophy, but the chambers were otherwise unremarkable.
The patient underwent emergency surgery with a diagnosis of acute aortic dissection. The aorta was opened, and 2 polypoidal structures resembling a tumor were removed, together with a piece of aortic tissue (Figure 1). There was no operative evidence of aortic dissection. Histopathological examination showed the mass to be a thrombus. The section of aorta did not show any atheroma, infection, or inflammation. Coronary arteries were normal.
The patient was anticoagulated with heparin and warfarin. On the tenth postoperative day, she presented with acute breathlessness and died. Autopsy revealed a large antemortem clot in the pulmonary artery with multiple pulmonary emboli, both acute and chronic. There was also evidence of multiple deep vein thromboses. The right atrium showed 6 to 7 polypoidal thrombi adherent to the walls (Figure 2) and a patent foramen ovale that was poorly guarded. The aorta was clean and there was no evidence of thrombus or dissection. In summary, this patient had multiple venous thrombi and presented acutely with evidence of arterial embolization to various sites (coronary, left radial, and ascending aorta) secondary to migration of thrombi across the patent foramen ovale.
Movies I and II are available in an online-only Data Supplement available at http://www.circulationaha.org.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.