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Ascending Aorta Thrombose: A Rare Cause of Simultaneous Acute Myocardial Infarction and Upper Limb Ischemia.

A 45 years old woman was transferred to our emergency department because of a 2 hours history of persistent central burning chest discomfort and pain begans suddenly at sleep time with associated nausea, vomiting and cold sweating that goes with paresthesia and pain in left arm. In past history she had diabetes mellitus on oral hypoglycemic agent therapy including Metformin 500 mg twice a daily and not mentioned other disease, but she used oral contraceptive pills (LD type) for 25 years since 20 years old. Her family history for cardiovascular diseases was negative. Initially the patient was awake and hemodynamically stable with arterial blood pressure 120/80 mmHg in right arm, heart rate about 88 beat per minute, respiratory rate 20 breath per minute, body temperature of 37.1 C and arterial O2 saturation 90%. The blood pressure in left arm was not detected. In left arm physical examination, she had no focal motor or sensory deficits, but she experienced numbness and the arm was pale and pulseless with slow capillary filling. Exam of heart, lung and other limbs were normal. At first a 12 leads electrocardiogram (ECG) was taken that showed ST-segment elevation in inferior leads (acute inferior MI) (Figure 1A). Laboratory findings were almost within the normal limits, with the exception of a slightly normochromic and normocytic anemia. Initial coagulation markers, such as platelet count, prothrombin and activated partial thrombin times, were also within normal ranges. Cardiac enzymes, including troponin I and D-dimmer were increased. A highly mobile echo dense mass (10 8 mm) in ascending aorta near the origin of right coronary cusp was detected accidentally during echocardiography assessment before coronary angiography (CAG) (Figure 1B). Other finding in echocardiography was normal except of a hypokinesia in base of inferior wall.