P1461 Concomitant potential cardioembolic sources in a patient with an acute ischemia of the limb
Authors: Carrington M , Briosa A , Quadrado M , Manuel A , Marques G , Ferreira M J , Joao I , Pereira H 
Published: January 2020

Abstract

Introduction
Transesophageal echocardiography (TEE) is the gold standard exam to look for a cardioembolic source in a patient with an otherwise unexplained suspected systemic ischemic event. Purpose: This clinical case aims to illustrate the importance of a thorough TEE evaluation in the presence of a suspected systemic emboli, and to not neglect thoracic aorta evaluation when a potential intracardiac cause has been detected. Case presentation: We present the case of a 55-year-old man, obese (BMI 30kg/m2), active smoker, with no past medical history or medication, and whose father died from an unspecified cardiovascular cause at 45 years-old. He was admitted to the hospital because of an acute ischemia of the right lower limb, for which he underwent urgent percutaneous femoral embolectomy of the limb, with success. During hospitalization, he was referred for a TEE, which showed valves and cavities with no evidence of potential embolic sources. However, he had a thin and hypermobile atrial septum, with no obvious defect after color flow mapping, but with a patent foramen oval (PFO) that was detected after agitated saline injection associated with a Valsalva maneuver, with the passage of 5-25 microbubbles (grade 2/4 shunt) and an atrial septum aneurysm (ASA), with an excursion of the fossa ovalis towards the left atrium of 10.1mm (Figure 1). The ascending aorta was normal, but the descending aorta depicted 2 hypermobile masses, 1 starting at 35cm from the dental arch (transversal area: 0,52cm2), the longest (7cm) starting at 32cm and ending at the aortic arch (transversal area: 1,76cm2). An angio-CT was immediately performed, which depicted an atheromatous calcified plaque in the terminal portion of the aortic arch, giving rise to the image suggestive of thrombus, and extending for about 6cm to the medium third of the descending thoracic aorta. The remaining portions of the aorta and iliac arteries depicted diffuse atheromatous and partially calcified plaques (Figure 2). The patient was submitted to an urgent thoracic endovascular aortic repair with a 26x10cm prosthesis implantation with occlusion of the left subclavian artery and an adequate final clinical result. Syphilis and auto-immune disease were excluded and a diffuse atheromatous disease of the aorta was assumed as the cause of the thrombus and the embolic event. After 16 days, he was discharged asymptomatic and with no signs of chronic ischemia, treated with oral anticoagulation with rivaroxabano, high-dose statin and strict smoking cessation. Conclusion: Cardioembolic source is a heterogeneous entity. In this patient, 2 potential cardioembolic sources were detected: while the PFO and ASA are minor or unclear risk sources of emboli, TEE also allowed for the detection of a large thrombus arising from an atherosclerotic calcified plaque in the thoracic aorta, which was considered a major risk source, thus implying urgent surgery to obviate the risk of further embolic events.
Abstract P1461 Figure. Fig.1.POF and ASA;Fig.2.Aortic Thrombus