Received Date: February 06, 2014; Accepted Date: May 15, 2015; Published Date: May 22, 2015
Citation: Abdallah H, Noly P, Elkhoury G. Unexpected Outcome of a Floating Thrombus in the Ascending Aorta. Journal of Surgery [Jurnalul de chirurgie] 2015; 11(2): 375-376 DOI:10.7438/1584-9341-11-2-5
Copyright: © 2015 Abdallah H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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We report the case of a 46-year-old woman, without any known systemic disease in the past, a history of car accident two months earlier with fracture of the left arm and the jaw. She presented to a local hospital, with prolonged precordial pain of ON/OFF occurrence, where acute coronary syndrome (ACS) was diagnosed and treated with conventional (aspirin, clopidegrel, β-blockers, heparin) treatment. She was then transferred to our hospital for cardiac catheterization. Coronary angiography showed normal coronary arteries, a moving filling defect was visible in the ascending aorta. An immediate transesophageal echocardiography revealed a free floating mass attached to the left cusp of the aortic valve .and occluding the left main coronary trunk, a trace of aortic valve regurgitation. The patient was hemodynamically unstable. Urgent operation was carried on and resection of the mass was done.
46-year-old female, without past medical history other than a caraccident causing a left arm and a jaw fracture, presented a syncopelasting couple minutes, to get up later with no neurological sequel. Sherefused to go to the hospital and have passed the whole day shopping.On arrival back home, she had a severe precordial pain of ON/OFFnature that obliged her to go to a local hospital, where acute coronarysyndrome (ACS) was diagnosed and treated with conventionaltreatment (aspirin, clopidogrel, nitroglycerin, and heparin). She wasthen transferred to our hospital for cardiac catheterization. On patientarrival, endotracheal intubation was performed, no abnormalitieswere found on examination of the heart, the electrocardiogram (ECG)showed ST-segment elevations in leads V2, V3, V4, V5, and V6. Thesupine chest X-ray showed mild pulmonary congestion with normalmediastinum. The systolic blood pressure was 90 mmHg, diastolic60 mmHg; the pulse rate was 82 bpm. BUN and creatinine werenormal. The total CK was 10000U/L A prompt coronary angiography was done which showed normal coronary arteries. A moving fillingdefect was visible in the ascending aorta (Figure 1). The patient washemodynamically unstable and intraaortic balloon pump was inserted.As the patient’s hemodynamic state deteriorated, conterpulsation wasimmediately terminated. A transesophageal echocardiography revealeda free floating mass (1,8 ×1,1cm) attached to the left cusp of the aorticvalve that resulted in occlusion of the left main stem during diastole ,severe septal and anterolateral wall hypokinesis, a trace of aortic valveregurgitation. The estimated left ventricular ejection fraction (LVEF)was 20%.
The patient was transferred immediately to the operation room.Through a median sternotomy, cardiopulmonary bypass (CPB) wasinstituted by means of cannulation of the ascending aorta and the rightatrium. Anterograde and retrograde cardioplegia were used. The aorticroot was transversely incised. A floating pedunculated mass attachedto an atherosclerotic plaque on the left cusp of the aortic valve wasfound. The mass was in close proximity to the left main stem ostium,causing intermittent occlusion of the latter (Figure 2). The mass wasexcised and the aortotomy was closed directly with a running suture.The aortic cross clamp time was 30 minutes. Sinus rhythm reumedearly after releasing the aortic cross clamp but it was impossible towean CPB despite inotropic drugs and IABP support. Transesophageal echocardiography revealed septal and anterolateral wall akinesis.The LVEF was estimated to be less than 5%. A central extracorporealmembrane oxygenation (ECMO) was then installed and the patientwas transferred to the intensive care unit. The immediate postoperativechest X-Ray showed moderate pulmonary congestion. On the secondpostoperative day, the chest X-Ray showed severe pulmonary edema.Cardiac contractility was evaluated by a daily echocardiography. On theseventh day, a better myocardial contractility was noted and the LVEFwas estimated at 20%. However, attempts to wean the ECMO supportwere unsuccessful, despite the use of inotropic drugs and IABP. Thepatient was kept on ECMO support for eight more days and died ofpulmonary hemorrhage awaiting a donor for cardiac transplantation.
Floating thrombi in the aorta are a rare finding in the absence of anycoagulation abnormality. They often represent a surgical emergency.This life threatening appears to be more common in female smokers intheir fifth decade.
Atherosclerosis, dissection, trauma, malignancy and coagulopathieshave been associated with aortic mural thrombi . Intraluminalthrombus may be located in the ascending aorta, even without extensiveatherosclerotic plaques .
In our patient, the origin of the aortic thrombus was atheromatousplaque/lesion located on left aortic valve cusp; the remaining cusps andthe ascending aorta were intact/free from atherosclerosis. The base ofthe thrombus was pedunculated to an atherosclerotic plaque locatedon the left cusp of the aortic valve .The mass was in close approximityto the left main coronary trunk, causing intermittent occlusion of thelatter.
Thrombolysis has been suggested as a promising therapy foraortic thrombus [3,4] and in some cases heparin and oral warfarinhave led to complete resolution in 3 months . However, longtermanticoagulation for the complete resolution of a floating,friable thrombus carries unacceptable risk of partial lysis and distalembolization.
Despite aggressive medical and surgical treatments, consequencesof a floating thrombus in the ascending aorta could be dramatic.
Walther et al. removed a thrombus from the aortic arch underhypothermic circulatory arrest, using retrograde perfusion throughthe femoral artery during extracorporeal circulation. In our patient,the thrombus was located in the first part of the ascending aorta.Therefore, we proceeded in routine way and we placed the arterialperfusion cannula in the proximal ascending aorta as for regular aorticvalve replacement, an anterograde and retrograde cardiopleagia wereused, aortic root was transversely incised. After the thrombus had beenexcised, the aortic incision was sutured with a double suture lines.
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