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Pedunculated aortic thrombus propagating from the right coronary artery in a patient with IgA nephropathy

Pedunculated aortic thrombus propagating from the right coronary artery in a patient with IgA... doi:10.1093/eurheartj/ehy282 CARDIOVASCULAR FLASHLIGHT .................................................................................................................................................... Pedunculated aortic thrombus propagating from the right coronary artery in a patient with IgA nephropathy 1 1 2 1 Jacques Scherman *, Natercia da Silva , Adriaan Myburgh , and Timothy Pennel Chris Barnard Division of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa; and Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa * Corresponding author. Tel: 12721 404 5185/12721 404 5017, Fax: 12721 448 1145, Email: jacques.scherman@uct.ac.za Clinical message A 52-year-old male patient, with a background of IgA nephropathy and hypertension presented with left- sided weakness, right-sided hemiano- pia, headaches, and a pre-syncopal attack. Electrocardiogram findings were consistent with an inferior ST- elevation myocardial infarction (STEMI) and cardiac enzymes elevated (TropT-level 3796 ng/L). Contrast tomography (CT)-brain demonstrated features consistent with a left poste- rior cerebral artery infarction, without haemorrhagic transformation. The source of the embolism was identified with transoesophageal echocardiogra- phy (TOE), (Supplementary material online, Video)revealing a1.3 1.3 cm pedunculated inhomogeneous mass originating from within the aortic root adjacent to the right coronary artery (RCA) ostium (Panels A–C), with fea- tures suggestive of proximal RCA occlusion (Panel B, arrow) and con- comitant inferoseptal hypokinesia. Urgent surgery was conducted via median sternotomy using cardiopul- monary bypass on an arrested heart for removal of the mass (Panel D) and embolectomy of the proximal RCA. Following this, intra- operative TOE confirmed good flow in the proximal RCA (Panel E, arrow). Dual antiplatelet therapy was commenced post-operatively, and the patient recovered uneventfully from surgery. The left-sided weakness almost completely resolved, as did the hemianopia. Histology revealed features consistent with an organizing thrombus. In view of the underlying renal dysfunction, a follow-up cardiac magnetic reso- nance imaging study was done which demonstrated an unobstructed proximal RCA (Panel Fi–iii) without any residual intracardiac- or coro- nary thrombus or mass. Primary aortic thrombi are rare in the absence of underlying atherosclerotic disease, and its aetiology relatively enigmatic. Amongst others, hypercoagulable states have been implicated as a risk factor. This rare case in a patient with IgA-nephropathy demonstrates the value of TOE to diagnose and delineate extent of involvement. Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. V The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy282/4996693 by Ed 'DeepDyve' Gillespie user on 13 July 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

Pedunculated aortic thrombus propagating from the right coronary artery in a patient with IgA nephropathy

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Oxford University Press
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.
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0195-668X
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1522-9645
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10.1093/eurheartj/ehy282
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Abstract

doi:10.1093/eurheartj/ehy282 CARDIOVASCULAR FLASHLIGHT .................................................................................................................................................... Pedunculated aortic thrombus propagating from the right coronary artery in a patient with IgA nephropathy 1 1 2 1 Jacques Scherman *, Natercia da Silva , Adriaan Myburgh , and Timothy Pennel Chris Barnard Division of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa; and Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa * Corresponding author. Tel: 12721 404 5185/12721 404 5017, Fax: 12721 448 1145, Email: jacques.scherman@uct.ac.za Clinical message A 52-year-old male patient, with a background of IgA nephropathy and hypertension presented with left- sided weakness, right-sided hemiano- pia, headaches, and a pre-syncopal attack. Electrocardiogram findings were consistent with an inferior ST- elevation myocardial infarction (STEMI) and cardiac enzymes elevated (TropT-level 3796 ng/L). Contrast tomography (CT)-brain demonstrated features consistent with a left poste- rior cerebral artery infarction, without haemorrhagic transformation. The source of the embolism was identified with transoesophageal echocardiogra- phy (TOE), (Supplementary material online, Video)revealing a1.3 1.3 cm pedunculated inhomogeneous mass originating from within the aortic root adjacent to the right coronary artery (RCA) ostium (Panels A–C), with fea- tures suggestive of proximal RCA occlusion (Panel B, arrow) and con- comitant inferoseptal hypokinesia. Urgent surgery was conducted via median sternotomy using cardiopul- monary bypass on an arrested heart for removal of the mass (Panel D) and embolectomy of the proximal RCA. Following this, intra- operative TOE confirmed good flow in the proximal RCA (Panel E, arrow). Dual antiplatelet therapy was commenced post-operatively, and the patient recovered uneventfully from surgery. The left-sided weakness almost completely resolved, as did the hemianopia. Histology revealed features consistent with an organizing thrombus. In view of the underlying renal dysfunction, a follow-up cardiac magnetic reso- nance imaging study was done which demonstrated an unobstructed proximal RCA (Panel Fi–iii) without any residual intracardiac- or coro- nary thrombus or mass. Primary aortic thrombi are rare in the absence of underlying atherosclerotic disease, and its aetiology relatively enigmatic. Amongst others, hypercoagulable states have been implicated as a risk factor. This rare case in a patient with IgA-nephropathy demonstrates the value of TOE to diagnose and delineate extent of involvement. Supplementary material is available at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. V The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy282/4996693 by Ed 'DeepDyve' Gillespie user on 13 July 2018

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European Heart Journal – Oxford University Press

Published: May 16, 2018

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