Bulgarian Cardiology · Published 2026-05-05 · DOI 10.3897/bgcardio.32.e186598
Floating thrombus of the aortic arch in the absence of aneurysm or atherosclerotic disease is an exceptionally rare condition. We report the case of a 47-year-old woman, an active smoker with iron-defi ciency anemia, who presented with acute retrosternal chest pain, dyspnea, diaphoresis, and vomiting. Initial evaluation showed arterial hypertension, sinus rhythm with poor R-wave progression in the precordial leads on electrocardiography (ECG), and markedly elevated high-sensitivity troponin levels, consistent with acute coronary syndrome. Transthoracic echocardiography (ТТЕ) revealed a large, highly mobile mass in the aortic arch prolapsing into the supra-aortic branches, reduced left ventricular systolic function and apical dyskinesia. Computed tomography angiography (CTA) confi rmed a fl oating thrombus attached to the lesser curvature of the aortic arch, mild non-obstructive coronary artery disease, and an apical left ventricular aneurysm. The patient was initially managed conservatively with unfractionated heparin and aspirin due to high procedural risk. However, despite therapeutic anticoagulation, she developed a transient cerebrovascular event, prompting urgent surgical intervention. Intraoperatively, a loosely attached mixed thrombus was excised from the aortic arch without evidence of atherosclerosis or endothelial injury. The postoperative course was uneventful. This case emphasizes the high embolic potential of fl oating aortic arch thrombi and supports early surgical consideration when embolic complications occur despite optimal anticoagulation.
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