Download Tear, Tumor, or Thrombus

Tear, Tumor, or Thrombus
T.P. Mathew, J.W. Cash, M. Sarsam and G.W.N. Dalzell
Circulation. 2002;105:e193
doi: 10.1161/01.CIR.0000018005.03030.7B
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2002 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circ.ahajournals.org/content/105/25/e193
Data Supplement (unedited) at:
http://circ.ahajournals.org/content/suppl/2002/06/24/105.25.e193.DC1.html
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published
in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial
Office. Once the online version of the published article for which permission is being requested is located,
click Request Permissions in the middle column of the Web page under Services. Further information about
this process is available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Circulation is online at:
http://circ.ahajournals.org//subscriptions/
Downloaded from http://circ.ahajournals.org/ by guest on July 8, 2012
Images in Cardiovascular Medicine
Tear, Tumor, or Thrombus
T.P. Mathew, MD; J.W. Cash, MB; M. Sarsam, MD; G.W.N. Dalzell, MD
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.
Figure 1. Tumor-like structures removed from ascending aorta
during surgery. The structures were later confirmed as thrombi.
Figure 2. Right atrium showing multiple thrombi (arrow)
attached to the walls (postmortem specimen).
From Regional Medical Cardiology Center, Royal Victoria Hospital, Belfast, N Ireland, United Kingdom.
Movies I and II are available in an online-only Data Supplement available at http://www.circulationaha.org.
Correspondence to Dr G.W.N. Dalzell, Regional Medical Cardiology Center, Royal Victoria Hospital, Belfast, N Ireland, BT12 6BA, United Kingdom.
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.
(Circulation. 2002;105:e193.)
© 2002 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
DOI: 10.1161/01.CIR.0000018005.03030.7B
1
Downloaded from http://circ.ahajournals.org/
by guest on July 8, 2012