Giant Organized Thrombus in the Left Sinus of Valsalva Causing Intermittent Left Coronary Obstruction-An Unusual Case of Acute Myocardial Infarction-

Native Aortic Valve Thrombus Complicating Intermittent Occlusion of a Left Main Coronary Artery

Intermittent left main coronary artery ostium obstruction (LMOO) caused by native aortic valve thrombus (NAVT) is an extremely rare condition. It may therefore be challenging to identify the cause using only coronary angiography, even though the clinical presentation and electrocardiography (ECG) strongly suggest myocardial infarction. We herein report a 53-year-old man with NAVT complicating intermittent occlusion of left main disease in preexisting coronary artery stenosis.

The Characteristics and Outcomes of Native Aortic Valve Thrombosis: A Systematic Review

BACKGROUND

There is a lack of knowledge in the current medical literature about native aortic valve thrombosis.

OBJECTIVES

The aim of this systematic review was to summarize the characteristics, presentations, underlying etiologies, and outcomes of native aortic valve thrombosis and to present a meta-analysis of the best available data.

METHODS

The authors performed a literature search, identified published cases of patients with native aortic valve thrombosis, and pooled the data in this meta-analysis. The statistical analysis included calculations of the prevalence of the various presentations, underlying etiologies, aortic cusp involvement, as well as choices of diagnostic testing. They calculated the sensitivities of the various diagnostic testing as well as in-hospital mortality event rates and the univariate ORs of the risk factors for poor outcomes.

RESULTS

The search strategy and screening process yielded 74 cases of native aortic valve thrombosis, which are included in this meta-analysis. The data revealed that the most common presentation was myocardial infarction in 36%, and the most common underlying etiology was hypercoagulable state in 30%. In-hospital clinical deterioration after presentation including recurrent embolism occurred in ∼38%, and in-hospital mortality rate was ∼20%.

CONCLUSIONS

Native aortic valve thrombosis is clinically relevant, especially in patients presenting with embolic events. Awareness about native aortic valve or root thrombosis as well as its underlying etiologies, diagnostic work-up, and management is essential, because this condition can be associated with poor outcomes.

Aortic Thrombus in a Nonaneurysmal Ascending Aorta

BACKGROUND

Ascending aortic thrombus (AAT) in a nonaneurysmal aorta is an extremely rare event and has potentially catastrophic complications, with a life-threatening risk of myocardial infarction and cerebral embolization. This systematic review aims to elucidate the clinical manifestations and to compare the outcomes of anticoagulation therapy versus open aortic surgery for AAT.

METHODS

The MEDLINE/PubMed databases were extensively searched between 1995 and 2019. All relevant publications on AAT in adults were reviewed, and individual patient data were pooled in this meta-analysis. The primary outcome was AAT resolution. The adverse outcome variables were recurrent arterial embolic events, complications related to open aortic surgery, and mortality during the study period. Chi-squared test and logistic regression analysis were used to compare groups and identify any predictors of mortality.

RESULTS

Overall, 107 patients from 101 articles were included, of whom 29 patients who received anticoagulation therapy and 59 who underwent open aortic surgery were included in the outcome analysis. Among 29 patients treated with initial anticoagulation therapy, the persistence of AAT was observed in 11 patients (38%) and recurrent arterial embolization was developed in 6 patients (21%). All 11 patients in the anticoagulation group underwent secondary aortic surgery for the persistence of AAT with uneventful postoperative course. Compared with patients treated with primary aortic surgery, patients treated with initial anticoagulation therapy had higher risk of recurrent embolization (P = 0.002). No significant difference existed in the mortality rates between the groups (P = 0.106). Hemodynamic instability was an independent predictor of mortality (P = 0.008).

CONCLUSIONS

Anticoagulation therapy and open aortic surgery for AAT show similar results; however, open aortic surgery reliably removes AAT and reduces the risk of recurrent embolization compared with anticoagulation therapy. Furthermore, the preoperative hemodynamic status significantly influences the clinical outcome and is a strong predictor of prognosis.

Sinus of Valsalva Thrombosis Detected on Computed Tomography after Transcatheter Aortic Valve Replacement

BACKGROUND AND OBJECTIVES

Leaflet thrombosis after transcatheter aortic valve replacement (TAVR) has been reported recently, whereas thrombus formation in sinus of Valsalva has yet to be fully evaluated. This study describes clinical and cardiac computed tomography (CT) findings of patients with sinus of Valsalva thrombosis.

METHODS

Between March 2011 and Aug 2019, 192 patients underwent cardiac CT after TAVR. After a retrospective review of CT images, 9 patients (82 years, male:female=2:7) who had sinus of Valsalva thrombosis identified by cardiac CT were selected for this study. Patient demographics, interval between TAVR and cardiac CT scan, location and CT attenuation of sinus of Valsalva thrombosis, and presence of concurrent leaflet thrombosis were evaluated.

RESULTS

The median interval between TAVR and cardiac CT was 11 days. Sinus of Valsalva thrombosis was frequently detected in the non-coronary sinus (89%, 8/9), and predominantly located in the bottom of the sinus extending upward towards the sinotubular junction. Three patients had concomitant leaflet thrombosis, and 3 patients had subclinical embolic stroke noted on brain magnetic resonance imaging. All patients had been prescribed aspirin and clopidogrel after TAVR for at least 6 months without anticoagulants.

CONCLUSIONS

Cardiac CT after TAVR can detect sinus of Valsalva thrombosis, and attention should be paid to this potential source of subsequent systemic embolization.

A rare cause of acute ST-elevation myocardial infarction: case report of native aortic valve thrombosis

Background

One to 13% of all patients with the clinical diagnosis of an acute coronary syndrome (ACS) show no evidence of significant obstructive coronary artery disease on angiography. Less common causes should be considered in those situations. A very rare cause of ACS is native aortic valve thrombosis.

Case summary

A 69-year-old previously healthy woman presented with acute chest pain. The electrocardiogram showed an anterolateral ST-elevation myocardial infarction (STEMI). She was immediately transferred for primary percutaneous coronary intervention. Shortly after arriving in hospital her condition deteriorated, with development of cardiogenic shock necessitating cardiopulmonary resuscitation. A coronary angiogram was performed during resuscitation that did not reveal any obstructive coronary artery disease. Echocardiography showed no pericardial effusion, no significant left-sided valve pathology, no signs of an aortic dissection or pulmonary embolism. She died of cardiogenic shock of unknown cause. Permission for autopsy was obtained. Pathologic examination revealed a large anterolateral myocardial infarction caused by a mass attached to the bottom of the left coronary cusp of the native aortic valve, which was large enough to occlude the ostium of the left main coronary artery. Microscopic analysis showed a thrombus of unknown origin. The aortic valve itself showed no signs of pathology.

Discussion

An ST-elevation myocardial infarction due to native aortic valve thrombosis is a rare condition, especially when there are no significant valvular abnormalities. This case demonstrates that thrombosis can develop in an apparently healthy middle-aged woman without any history of thrombotic disease.

Native aortic valve thrombosis resembling papillary fibroelastoma

The differential diagnosis of cardiac mass is important in determining the therapeutic plan and avoiding unnecessary surgical intervention. Non-invasive imaging methods would be useful in the diagnosis of suspected cardiac mass, because they may provide earlier diagnosis and more accurate assessment of cardiac mass. Native aortic valve thrombosis is a rare disorder and difficult to differentiate from a tumor, and in particular, a papillary fibroelastoma. Thus, the clinical decision making with imaging modalities should be performed cautiously. We recently met a female patient who had a aortic valve mass resembling papillary fibroelastoma in normal native valve. The patient underwent a surgical resection and the pathologic finding showed an organized thrombus with no evidence of papillary fibroelastoma.

Two consecutive fatal cases of acute myocardial infarction caused by free floating thrombus in the ascending aorta and review of literature

Free floating thrombus in the ascending aorta is an uncommon source of acute myocardial infarction. We report on two cases of young women who died of acute myocardial infarction caused by a free floating thrombus in the sinus of Valsalva obstructing the coronary arteries' ostia. The first case reports on a 30-year-old pregnant woman who anamnestically had episodes with short loss of consciousness and weakness. The second case presents a 37-year-old woman suffering from multiple sclerosis with no previous history of thrombotic events. The review of literature revealed a predominance of women (eight females and three males). Interestingly, the coronary arteries bear no preference concerning the right (RCA) or left coronary artery (LCA) being more often occluded by a free floating thrombus. Especially, younger women (mean age 45.5 years, range 30-59 years) with no history of cardiac symptoms and without atherosclerotic changes seem to be predispositioned. The hypothesis that thrombus formation in cases without plaque disruption may depend on an endothelial erosion which seems to be more common in younger women and promoted by a hyperthrombogenic state is supported by our two cases. A comprehensive literature search revealed, that these are the first two reports on a free floating thrombus being the cause of fatal acute myocardial infarction in a pregnant woman, respectively, a woman suffering from multiple sclerosis.

Acute coronary syndromes associated with thrombus in the sinus of valsalva and normal coronary arteriography: the pivotal role of transesophageal echocardiography in the intensive care unit

We describe 4 patients with thrombus in nonaneurysmal sinus of Valsalva. The diagnosis was made with transesophageal echocardiography performed in the Intensive care unit, in the setting of acute coronary syndromes. Coronary arterlography showed normal coronary arteries in each patient. In 3 patients, conservative medical therapy resulted in full recovery. Two patients had previously undergone aortic valve surgery.

Sinus of Valsalva thrombosis causing renal infarction

A 72-year-old man was admitted to our hospital with a renal infarction. On admission, computed tomography (CT) of the abdomen revealed total occlusion of the right renal artery, which was found to be recanalized with residual thrombus 7 days later. Transesophageal echocardiography and chest CT demonstrated crescent-shaped thrombus in the non-coronary sinus of Valsalva without evidence of aneurysm. After coumadin treatment the patient did not experience recurrent episodes of systemic embolization. Five months after the initiation of anticoagulation, transesophageal echocardiography and chest CT demonstrated disappearance of the thrombus. This is a rare case of renal infarction caused by a thrombus in the non-coronary sinus of Valsalva without aneurysm.