Fungal mycotic vegetation in the ascending aorta.

In most clinical scenarios, the appropriate diagnostic methodology and treatment plan can be determined in a timely manner. However, complex clinical cases with obscure etiology can be deceptive, and a multidisciplinary approach can help to clarify things. At the Methodist DeBakey Heart & Vascular Center, we encountered a huge progressive mass in the ascending aorta in a 50-year-old chronic hemodialysis patient after mechanical aortic valve replacement. In addition to initial image diagnosis and consultation workups, a transcranial Doppler (TCD) study identified continuous generation of microemboli that suggested the need for urgent surgical resection instead of conservative heparin IV therapy. Histopathology showed the huge friable mass to be hyphenated fungal mycosis (Aspergillus or Fusarium) and necrotic tissue surrounded by fresh thrombus. The postoperative course was uneventful, and the patient was discharged home.