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A 37 year old woman was admitted because of acute non-ST segment elevation myocardial infarction. Treatment with nitrates, β blocker, aspirin, and heparin was initiated. The next day her ECG revealed new Q waves with a negative T wave in lead II, III, and aVF (inferior wall infarction); blood chemistry was also clearly indicative of myocardial infarction (creatinine phosphokinase 2800 U/L, myocardial bound fraction 447 U/litre). Because of recurrent chest pain coronary angiography was performed, which showed a proximal occlusion of the right coronary artery; the left coronary artery was normal. In the ascending aorta a free floating tumour was identified, which could have been a large thrombus or vegetation resulting from aortic valve endocarditis (below left). Transoesophageal echocardiography was performed and a thrombus-like free floating tumour was seen in the proximal ascending aorta, originating in the proximal right coronary artery (below right, arrow). Aortic valve endocarditis was excluded.
Because of risk of embolisation, immediate cardiopulmonary bypass surgery was performed. The tumour was easily removed from the ascending aorta and the ostium of the right coronary artery.
Histological examination confirmed the diagnosis of a thrombus. Elaborate haematological evaluation of the coagulation status of the patient showed no abnormalities.
Review of the literature has revealed only one previous case, in which the death of a 42 year old man was caused by a large, free floating thrombus in the ascending aorta and originating from the main stem of the left coronary artery.