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JAMA Cardiology Clinical Challenge
January 2018

75-Year-Old Woman With Multiple Systemic Emboli

Author Affiliations
  • 1Department of Medicine, Advocate Lutheran General Hospital, Park Ridge, Illinois
  • 2Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois
JAMA Cardiol. 2018;3(1):84-85. doi:10.1001/jamacardio.2017.3262

A 75-year-old woman recently diagnosed as having stage IV lung adenocarcinoma was admitted for dyspnea and weakness. There was no history of illicit drug use, autoimmune disease, or cardiopulmonary disease. Physical examination was remarkable only for asthenia. Cardiac examination was normal. Chest computed tomography (CT) demonstrated multiple pulmonary nodules, a spiculated mass in the right medial upper lobe, vertebral metastases, and small bilateral subsegmental pulmonary emboli. Cranial CT showed scattered subacute embolic cortical infarcts and dural metastases. Serum troponin was 2.6 ng/mL (type 2 myocardial infarction) with nonspecific electrocardiographic changes. Transthoracic echocardiogram showed normal biventricular function with normal wall motion and shaggy, bulky masses on the tips of both mitral valve leaflets (Figure) (Video 1). A saline contrast bubble study was negative for an intracardiac shunt, and commercial intravenous contrast showed no clot. Transesophageal echocardiogram showed large, 1.4 × 0.5-cm, frondlike, mobile masses on the atrial surface of the mitral leaflets with mild mitral regurgitation. In addition, a large 1.1  × 1.6-cm multilobulated, mobile mass was seen on the subvalvular chordae of the tricuspid valve, with trace tricuspid regurgitation. Gated cardiac CT angiogram confirmed mobile hypoattenuating masses on the mitral valve leaflets that prolapsed to the left atrium during systole (Video 2). No myocardial, pulmonary vein, or pericardial involvement was seen.

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