https://orcid.org/0000-0003-3719-7655
A 49-year-old man with no past medical history presented to the emergency department with normal vital signs and physical examination, complaining of chest pain radiating to the right shoulder.
The ECG showed normal atrioventricular and intraventricular conduction with T wave inversion in the anterolateral leads (Panel G).
Laboratory tests showed normal troponin and elevated D-dimer levels (6751 ng/mL).
A transthoracic echocardiogram, despite poor visualization of the parasternal window, showed normal left ventricular function without segmental contraction abnormalities. High D-dimer levels prompted a “triple rule-out” CT, which confirmed bilateral pulmonary embolism (Panel C), a 3.5 cm pedunculated mass in the ascending aorta (Panel B), and proximal stenosis of the LAD (Panel D).
The case was discussed in the Heart team and, given the size of the mass and its probable thrombotic nature, urgent surgical resection was planned to avoid life-threatening embolization. Pre-operative transoesophageal echocardiography (Panel A, see Supplementary data online, Video S1) showed a pedunculated mass originating above the right coronary ostium. The patient underwent median stenotomy and aortotomy, and visual inspection (Panel E) revealed no aortic wall abnormalities, so the mass (Panel F) was removed without replacement of the ascending aorta.
Histological analysis confirmed the thrombotic nature of the mass, but laboratory and instrumental studies failed to identify a clear prothrombotic cause. Anticoagulation was started immediately.
We decided against immediate revascularization of the LAD stenosis in favour of an elective study due to the prohibitive risk of pre-mass resection coronary angiography, normal troponin levels, and normal echocardiographic findings.
Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.
Funding: This research was conducted entirely within the Marche University Hospital, specifically within the Cardiology and Arrhythmology Clinic, and Cardiac Surgery Unit. No external funding was received for this study.
Data availability: The data supporting the findings of this image focus are available upon request from the corresponding author. Requests for data should be addressed to Luca Finori at [email protected]. Access to the data will be provided in compliance with any applicable laws and regulations regarding data sharing and patient privacy.
Author notes
A.B. and L.F. contributed equally to this work.
Conflict of interest: None declared.
