A rare case of native thrombotic aortic valve thrombosis with acute coronary syndrome like presentation

BACKGROUND: Thrombosis of the native aortic valve is a rare, potentially embolic condition that has been increasingly identified with modern imaging and can present variably from myocardial infarction to stroke, limb ischemia, or be clinically silent. We present an idiopathic native aortic valve thrombus manifesting as suspected acute coronary syndrome. CASE PRESENTATION: An 84-year-old man with multiple cardiovascular risk factors and a history of opium use presented with chest pain, sweating, and vertigo. Initial evaluation showed severe three-vessel coronary artery disease and chronic cerebral ischemic changes. Echocardiography revealed impaired left ventricular function, an apical thrombus, and a suspicious thickening on the non-coronary cusp of the aortic valve. He underwent coronary artery bypass grafting, during which a firm valvular mass was identified and excised. Histopathology confirmed organized thrombus without malignancy or infection. The postoperative course was uneventful. CONCLUSION: This case emphasizes that valve-attached thrombi can present atypically in elderly patients with vascular risk factors; targeted valve imaging and combined surgical removal plus anticoagulation may be required.