A Phantom in the Aortic Valve: Tumor, Thrombus, or Artifact?

A 37-year-old man presented to the authors' institute with complaints of angina on exertion for the last 2 months. His past history was relevant for acute coronary syndrome in 2002, which was treated with a stent to the left anterior descending artery. A recent coronary angiogram revealed 80% stent stenosis of the left anterior descending artery with total occlusion of the circumflex artery (after the first obtuse marginal branch) as well as the right coronary artery (after origin). Preoperative transthoracic echocardiography showed normal left ventricular function and no valve abnormalities. Clinical examination was unremarkable, and routine biochemical investigations were within normal limits. After the induction of anesthesia, a echocardiography probe was inserted, and images were acquired and archived on a Philips iE 33 machine (Philips, Bothell, WA). Apart from confirming the preoperative findings, an echogenic circular mass was seen in the left coronary cusp in the modified midesophageal short-axis view of the aortic valve at 0° (Fig 1 and Video 1 [supplementary videos are available online]). The mass was again visualized in the short-axis view of the aortic valve at 45°; however in this view, the mass was seen lying in the noncoronary cusp (Fig 2 and Video 2). What is the diagnosis?