LAUSR

Antiphospholipid syndrome (APLS) carries numerous cardiovascular complications due to recurrent arterial and venous thromboembolism. However, thrombosis of native aortic valve in primary APLS is a rare finding and the role of novel anticoagulant is not well-understood. A 45 years-old woman with primary APLS complicated by previous right superficial femoral artery thrombosis requiring below-the-knee amputation, superior mesenteric artery thrombosis, stroke, and on apixaban due to recurrent spontaneous thrombosis, presented with acute right temporoparietal infarction. Transesophageal echocardiogram showed a large homogeneous mass (white arrow) on the noncoronary cusp of aortic valve, measuring 1.3 1.4 cm. Panels A and B are long-axis images in diastole and systole, respectively. Panels C and D are short-axis images during diastole and systole, respectively. Abbreviations are RCC, right coronary cusp; LCC, left coronary cusp; LVOT, left ventricular outflow tract; and Ao, aorta. The mass had a large base with a mobile superficial surface limited to the cusp. Panel E shows cardiac magnetic resonance image of a sessile mobile mass attached to the noncoronary cusp without dynamic contrast perfusion or late enhancement. Patient underwent successful surgical extraction of the mass and was discharged on clopidogrel and warfarin. Panel F shows the final histopathology with aggregates of fibrin with entrapped erythrocytes and leukocytes, consistent with thrombus, and no malignancy identified. The case illustrates the atypical location for thrombus formation in APLS, benefit of multiple cardiac imaging modalities, and treatment failure with novel anticoagulant. Future clinical research is needed to better characterise cardiac thrombus and optimal treatments for APLS patients.