A 76 year old man presented with severe abdominal pain, vomiting, and signs of lower right limb ischaemia. The patient had no previous medical history but smoked cigarettes. The ECG and transthoracic echocardiography showed no significant abnormality. Computerised tomography of his abdomen demonstrated multiple renal and splenic infarcts. The patient underwent emergency right femoral embolectomy and was anticoagulated with intravenous heparin.

A transoesophageal echocardiogram was requested. This revealed a normal heart with no evidence of intracardiac shunt. The descending aorta was visualised at the end of the procedure and there was a large pedunculated thrombus measuring 4 × 2 cm (panel A, video clip 1) (to view video footage, visit the Heart website—http://www.heartjnl.com/supplemental). Thrombolysis was considered, but in view of the risk of precipitating further emboli, the patient was anticoagulated with warfarin. The patient remained free from further embolic events. Transoesophageal echocardiography three months later revealed a smooth, posteriorly located plaque in the descending aorta (fig 2) with no evidence of residual thrombus.

This report demonstrates the additional value of transoesophageal echocardiography in identifying a source of arterial embolisation. It is recognised that aortic atheromatous plaques are a potential source of embolism. Overlying aortic thrombi are a rare but potentially underestimated source of systemic emboli. Undiagnosed and untreated, they may have catastrophic consequences. In this case, although transthoracic echocardiography was normal, a giant thrombus in the descending aorta was found on a transoesophageal study. Transoesophageal echocardiography should be considered when there is high level of suspicion of a cardiac source of embolism.