Large Thrombus in the Ascending Aorta Successfully Treated by Thrombolysis

Abstract

cute myocardial infarction (AMI) is confirmed by angiographic evidence of coronary artery occlusion, which is usually caused by a thrombus or by atherosclerosis. 1 A thrombus located close to the orifice of the coronary artery in the ascending aorta in connection with AMI is rare, 2,3 but we report such a case and discuss the thrombogenetic role of risk factors and the therapeutic strategy of thrombolysis. Case ReportA 52-year-old woman complained of chest pain in the morning of 13 September 1993 and was transferred to a local hospital with suspected AMI diagnosed by electrocardiography (Fig 1). She was immediately referred to us. She smoked 20 cigarettes per day, and was taking hormone supplement therapy (Ovulen), which consisted of mestranol (50 g/tablet) and ethynodiol diacetate (1 mg/tablet), for menopausal symptoms of flushing and mental irritability. In addition, for the past 20 years she had taken the contraceptive pill occasionally to treat uterine endometriosis. Moreover, she had had a mentally stressful day before the cardiac event because of trouble with her family. However, she had been well without a history of cardiac symptoms before this episode.On admission, the pulse rate was 120 beats/min and regular, and peripheral pulses were normal. She looked pale and her blood pressure was 82/65 mmHg.Emergency cardiac catheterization revealed that the right coronary artery (RCA) was well developed without luminal stenoses, but the left coronary artery (LCA) was not apparent. The left sinus of Valsalva was searched for the orifice of the LCA, but it could not be found, so contrast media was injected into the left sinus of Valsalva and then into the proximal ascending aorta. Angiography revealed a large filling defect protruding from the aortic wall close to where the LCA opens into the ascending aorta (Figs 2-4).Intraaortic balloon counterpulsation was promptly performed, followed by the intravenous tissue plasminogen activator, alteplase, first by rapid intravenous injection of 2.4×10 6 IU/L, and then by drip infusion of 21.6×10 6 IU/L within 1 h.One hour after beginning the thrombolytic therapy, the patient suddenly became free of chest pain, but developed cardiogenic shock with ventricular tachycardia. Full cardiac resuscitation with repeated electrical countershocks was performed and she eventually recovered sinus rhythm. After recovery, she underwent echocardiography, but evidence of thrombus around the orifice of the LCA could not be detected.Laboratory data, such as platelet count, hematocrit and serum cholesterol level, were within normal limits, and antithrombin III was 24.3 ng/ml. Peak creatine kinase, aspartate aminotransferase, alanine aminotransferase and lactate dehydrogenase were 11,000 IU/L, 1,280 IU/L, 250 IU/L and 5,700 IU/L, respectively.One month later, we performed follow-up cardiac cath- A 52-year-old woman suffered from acute massive myocardial infarction in association with a large thrombus in the ascending aorta. She was a moderate smoker and was taking hormone supplement therapy fo...

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

“…3,[5][6][7] We provided definitive echographic evidence that a mobile mass provoked intermittent left coronary occlusion. Ito et al reported the use of thrombolytic therapy for fresh thrombus in the ascending aorta, 4 but we did not consider the mass to be fresh thrombus on the basis of TEE findings and thus surgical treatment was employed. Our experience suggests TEE is particularly useful for showing not only the anatomical structure but also its characteristics when a thrombus or tumor is suspected in the sinus of Valsalva.…”

“…Thrombosis in the ascending aorta [2][3][4][5] or in the sinus of Valsalva 6,7 associated with AMI is a very rare condition. As much as 150 years ago, Rudolf Virchow pointed out 3 important factors necessary for thrombus formation; namely, abnormalities in blood flow, blood constituents, and the vessel wall, which are now referred to as Virchow's triad.…”

“…The commonly accepted therapeutic strategies for thoracic aortic thrombus have not been established yet, and therefore the therapeutic approach will differ according to the characteristics of the thrombus. 4 The TEE findings can assist in the decision of the therapeutic approach.…”

Plural large floating thrombi in the ascending aorta

“…However, an aortic mural thrombus in a non-aneurysmal mildly atherosclerotic or normal aorta is a very rare clinical entity [1,3]. Therefore, with respect to the primary management for this unusual problem, many physicians are at a loss which to choose [4,8].…”

“…Both anticoagulation therapy (including thrombolysis) and aortic surgery are commonly used as primary treatment [2][3][4][5]8], but there is no consensus. The results of the literature described above [1] showed that mortality rates were similar between groups; however, patients who received anticoagulation medication as primary therapy tended to have more complications such as stroke, limb loss, and bowel resection.…”