An 87-year-old woman was referred to our institution after reporting syncope. Examination revealed tachycardia (140 beats per minute), cold extremities and clinical signs of elevated jugular venous pressure; her blood pressure was 60/50 mmHg and blood oxygen saturation was 80%. Electrocardiogram showed S1 Q3 and right bundle branch block patterns. Transthoracic echocardiogram revealed a dilated and hypokinetic right ventricle (estimated systolic pulmonary artery pressure 65 mmHg) and an aortic root aneurysm (sinuses of Valsalva: 70 mm). A large serpentine thrombus was trapped in the mitral valve ( Fig. 1 ). Contrast-enhanced computed tomography showed bilateral pulmonary embolism associated with aneurysm of the ascending aorta ( Fig. 2 ). Neither surgical embolectomy nor thrombolytic therapy was performed due to the patient’s poor general condition. Medical treatment with saline fluid loading, intravenous unfractionated heparin and oxygen therapy (6 L/min from a medium concentration mask) was started. Venous ultrasonography showed no evidence of deep venous thrombosis in the legs. Evolution was favourable with disappearance of the embolus. The patient did not present clinical evidence of systemic embolism and was discharged home with good autonomy with fluindione at day 34.
