Transmitral excision of primary left ventricular thrombi presenting with acute limb ischemia

A 54-year-old Caucasian woman with a history of type II diabetes mellitus and smoking was admitted to the hospital for evaluation of pain and weakness in her right leg. She was found to have diminished strength in the right lower extremity, complete loss of sensation extending from the right foot to the mid-calf, and no palpable dorsalis pedis or posterior tibial pulses. She had normal sensation and strength in the left lower extremity but was noted to have a weak dorsalis pedis pulse on the left. She was diagnosed with acute right lower extremity ischemia due to an occluding thrombus at the aortic bifurcation on computed tomographic angiography (Figure 1). She was taken to the operating room emergently by vascular surgery and underwent bilateral femoral cutdowns with thrombectomy of her bilateral aortoiliac arteries. She was started on systemic anticoagulation postoperatively, and investigations for possible sources of thromboemboli were performed. A transthoracic echocardiogram showed 2 mobile echodensities in the left ventricle (Figure 2). The first was a large mobile echodensity (2.3 cm × 2.1 cm) appearing to have a stalk attached to the anterior wall of the left ventricle. The second mobile echo density (1.0 cm × 0.5 cm) was attached to the apex of the left ventricle. Which of the following is not a likely cause of her findings?

• A.
  Myxoma
• B.
  Angiosarcoma
• C.
  Aortic stenosis
• D.
  Ventricular thrombus