Mobile debris in the aorta

An 81-year-old woman was admitted to our institution for acute heart failure due to severe aortic valve stenosis. With respect to elevated predictive surgical risk scores and her frailty, our heart team decided to assess the patient for transcatheter aortic valve implantation (TAVI). Three-dimensional transoesophageal echocardiography (TEE) was performed to obtain aortic annular dimensions and showed an abnormal mobile echogenic structure attached to the aortic wall suggestive of a complex atheroma plaque with adherent mobile thrombi at the junction between the aortic arch and descending aorta (Fig. 1A, Appendix A supplementary AVI files). ECG-gated CT angiography however did not detect any suspect mobile structure (Fig. 1B). The procedure was delayed and after 3 months of well-adapted anticoagulation therapy, repeated TEE showed no significant change (Fig. 1C). We thus decided to perform TAVI using transapical approach in order to avoid dragging and embolization of the mobile debris into the supra-aortic vessels. Post TAVI TEE showed persistence of the mobile debris. The patient had an uneventful recovery and was discharged with a treatment of aspirin 100 mg and clopidogrel 75 mg, daily. One-year follow-up was free of any major adverse events.