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Mobile ascending aortic mass presenting as acute myocardial infarction

  • Hellmuth R. Muller Moran
  • Calvin Loewen
  • Vikas Dutta
  • Pallav J. ShahEmail author
Images in Anesthesia
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A 56-yr-old (62 kg) man (who provided written consent to publish this report) with no documented medical history presented to the emergency department after eight hours of chest pain. With a normal electrocardiogram and a troponin T level of 2720 ng·L−1 (normal range 0-14 ng·L−1), he was subsequently diagnosed with a non-ST segment elevation myocardial infarction. Transthoracic echocardiography unexpectedly revealed a 1.3 × 1.7 cm mobile mass in the ascending aorta close to the left main coronary ostium.
Figure

A) Two-dimensional transesophageal echocardiographic (TEE) short-axis image of the aortic root shows a thrombotic mass (white arrow) close to the the left main coronary artery (red arrow) ostium. B) Three-dimensional TEE long-axis image similarly shows the mass (black arrow) in the ascending aorta. A video of the mobile mass is available as Electronic Supplementary Material. LA = left atrium; PA = pulmonary artery; RA = right atrium

He was scheduled for urgent resection of the mass under cardiopulmonary bypass (CPB), at which time transesophageal echocardiographic examination further characterized the mass (Figure A and B). It appeared to be encapsulated with a very small stalk of attachment immediately adjacent to the left main coronary ostium. The mass was resected en bloc, with the associated aortic wall removed by shave excision. The aorta was closed, and the patient was weaned from CPB and transferred to the intensive care unit.

As postoperative coronary angiography did not reveal any obstructive coronary artery disease, the patient’s initial presentation was thought to be due to either embolization or transient occlusion of the left main coronary artery. He was discharged home on postoperative day 7 after an uneventful course in hospital.

Pathological examination revealed that the mass was composed entirely of thrombus, with portions showing evidence of hyaline degeneration, suggesting that the mass had been present for quite some time. As no bacterial or fungal organisms were isolated, and the patient had no known hypercoagulability disorder or atherosclerotic disease, the source of the thrombus remained unclear.

Notes

Acknowledgments

The authors thank Dr. Eric Jacobsohn and Dr. Hilary P. Grocott for their assistance in preparing this publication.

Conflicts of interest

The authors declare that there are no conflicts of interest related to this work.

Editorial responsibility

This submission was handled by Dr. Philip M. Jones, Associate Editor, Canadian Journal of Anesthesia.

Funding

No funding was used to conduct this work.

Supplementary material

Supplementary material Three-dimensional transesophageal echocardiography long-axis view of the aortic root shows the mobile mass intermittently obstructing the ostium of the left main coronary artery. (MP4 8889 kb)

Copyright information

© Canadian Anesthesiologists' Society 2018

Authors and Affiliations

  • Hellmuth R. Muller Moran
    • 1
  • Calvin Loewen
    • 2
  • Vikas Dutta
    • 2
  • Pallav J. Shah
    • 1
    Email author
  1. 1.Department of Surgery, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
  2. 2.Department of Anesthesia & Perioperative Medicine, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada

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