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Mobile complex atherosclerotic aortic plaque
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  1. Rishi Bajaj,
  2. Lovely Chhabra,
  3. Mihaela Kruger,
  4. Deepti Kumar
  1. Department of Internal Medicine, Division of Cardiology, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, Massachusetts, USA
  1. Correspondence to Dr Lovely Chhabra, lovids{at}hotmail.com

https://doi.org/10.1136/bcr-2013-009542

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    Description

    A 64-year-old man with a history of paroxysmal atrial fibrillation (AF) and transient ischaemic attack was admitted with complaints of palpitations and fatigue. He was found to be having AF with sustained rapid ventricular response. He had failed rate control therapy with calcium channel blockers and antiarrhythmic therapy (dronedarone), and was on dabigatran for anticoagulation. Prior to undergoing direct current cardioversion, he underwent a transoesophageal echocardiogram (TEE) to rule out left atrial appendage (LAA) thrombus which revealed a large, complex atherosclerotic plaque (size 0.5 cm) in the aortic arch extending into the descending thoracic aorta with several highly mobile lesions attached to the plaque (largest size 0.96 cm) (figures 1 and 2; videos 1 and 2). There was no LAA thrombus and the patient was successfully cardioverted to sinus rhythm and started on simvastatin.

    Figure 1
    Figure 1

    Short-axis view of the aortic arch showing a large complex plaque on transoesophageal echocardiography. One large mobile lesion is seen attached to the plaque.

    Figure 2
    Figure 2

    Long-axis view of the aortic arch showing a complex plaque on transoesophageal echocardiography.

    video 1

    Short-axis echocardiographic view of the aortic arch showing a large complex plaque on transoesophageal echocardiography. One large mobile atheroma is seen attached to the plaque.

    video 2

    Long-axis echocardiographic view of the aortic arch showing a large, complex plaque on transoesophageal echocardiography. One large mobile atheroma is seen attached to the plaque.

    Aortic arch atheroma is a strong risk factor for atheroembolic stroke. Despite antiplatelet therapy, it carries a risk of recurrent strokes, as high as 11% at 1 year.1 In particular, plaques 4 mm or greater in thickness proximal to the origin of the left subclavian artery are found in one-third of patients with otherwise unexplained stroke.2 TEE can provide information regarding plaque composition, mobility, ulceration as well as anatomic relationship of the plaque to the origin of the great vessels with excellent intraobserver and interobserver reproducibility. Treatment with a statin is a reasonable option for patients with aortic arch atheroma to reduce the risk of stroke.3 Oral anticoagulation therapy may be considered in stroke patients with aortic arch atheroma 4 mm or greater to prevent recurrent strokes.4

    Learning points

    • Aortic arch atheroma is a strong risk factor for atheroembolic stroke and peripheral thromboembolism. The risk remains very high despite antiplatelet therapy.

    • Oral anticoagulation may be considered in stroke patients with aortic arch atheroma (size 4 mm or greater), to prevent recurrent strokes.

    References

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      The French Study of Aortic Plaques in Stroke Group. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med 1996;2013:1216–21.
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      2. Mitusch R,
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      . Aortic atherosclerotic plaques as a source of systemic embolism. J Am Coll Cardiol 1996;2013:664–9.
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      1. Tunick PA,
      2. Nayar AC,
      3. Goodkin GM,
      4. et al
      . Effect of treatment on the incidence of stroke and other emboli in 519 patients with severe thoracic aortic plaque. Am J Cardiol 2002;2013:1320–5.
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    4. ↵
      1. Dressler FA,
      2. Craig WR,
      3. Castello R,
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      . Mobile aortic atheroma and systemic emboli: efficacy of anticoagulation and influence of plaque morphology on recurrent stroke. J Am Coll Cardiol 1998;2013:134.
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    View Abstract

    Footnotes

    • Competing interests None.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.