Presentation
Acute onset chest pain radiating through to the left shoulder blade with lactate 5.7, normal ECG, ongoing pain, ? dissection
Patient Data
Non-contrast and arterial phase contrast-enhanced exam.
The images are degraded by motion.
No intramural hematoma, penetrating ulcer or thoracic aortic dissection. No aneurysm. Normal configuration of the branches of the arch of the aorta.
No pericardial effusion.
Low attenuation filling defect within the aortic root lumen measures approximately 2 x 1.7 cm and appears associated with the aortic valve, likely involving both anterior and posterior coronary cusps, although the images are degraded at this level. No distal filling defects are seen in the scanned volume.
Minor interstitial thickening of the right middle lobe and right upper lobe anteriorly in keeping with previous radiotherapy. Right breast surgical clips noted.
Mild bilateral dependent changes and left basal atelectasis. No concerning pulmonary nodules. No pleural effusion.
The partially imaged upper abdominal solid viscera are unremarkable.
No concerning bony abnormality.
Opinion:
No evidence of acute aortic syndrome. Aortic valve vegetation/thrombus as described. I note the patient has a raised WCC raising the possibility of bacterial endocarditis. Urgent cardiology referral is advised. No distal thrombus is demonstrated in the scanned volume.
Case Discussion
Radiological finding of a filling defect at the aortic valve was initially missed on call by the author, and detected when the exam was checked the next day.
No organisms were ever cultured on multiple blood cultures.
The patient proceeded to theater for aortic valve replacement, a mass was seen surgically, which was sent for pathological analysis. On histology the mass demonstrated mature inflammatory changes, no evidence of dysplasia and no micro-organisms stained, however the appearances were described as being in keeping with endocarditis.
The patient remains under cardiology follow-up.