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Ann Thorac Surg 1998;66:248-250
© 1998 The Society of Thoracic Surgeons

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Case Reports

Video-assisted cardioscopy for left ventricular thrombectomy in a child

^a Division of Cardiovascular Surgery, Miami Children’s Hospital, Miami, Florida, USA
^b Department of Cardiology, Miami Children’s Hospital, Miami, Florida, USA
^c Division of Thoracic and Cardiovascular Surgery, All Children’s Hospital, St. Petersburg, Florida, USA

Accepted for publication January 28, 1998.

Address reprint requests to Dr Burke, Division of Cardiovascular Surgery, Miami Children’s Hospital, 3200 SW 60 Court, Suite 102, Miami, FL 33155-4069

	Abstract

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Left ventricular thrombus is a complication of myocardial infarction, ventricular aneurysm, cardiomyopathy, and myocarditis. Left ventriculotomy has been the standard approach for removal of left ventricular thrombus. This approach has produced an unacceptable incidence of ventricular dysfunction, arrhythmias, and aneurysm formation. We describe a case of left ventricular thrombus with systemic embolization in a patient with myocarditis. Video-assisted cardioscopy allowed visualization and removal of the thrombus via an aortotomy, thereby avoiding a left ventriculotomy.

	Introduction

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Left ventricular thrombus is a common complication of myocardial infarction, ventricular aneurysm, idiopathic dilated cardiomyopathy, and myocarditis [1]. The risks of systemic embolization and left ventricular outflow tract obstruction may prompt surgical intervention. Left ventriculotomy has been the standard approach for removal of left ventricular thrombus. This approach has produced an unacceptable incidence of ventricular dysfunction, arrhythmias, and left ventricular aneurysm formation [2]. We describe a case of left ventricular thrombus with embolization to the left subclavian artery in a patient with viral myocarditis. Video-assisted cardioscopy (VAC) allowed visualization and removal of the thrombus via an aortotomy, thereby avoiding a left ventriculotomy.

A 17-year-old girl presented with fever, vomiting, and diarrhea. Four days later, chest pain and dyspnea developed. The chest film revealed cardiomegaly. Echocardiography revealed a 3-cm apical left ventricular thrombus with decreased left ventricular function and a small posterior pericardial effusion. The thrombus was well circumscribed, pedunculated, and mobile.

After admission, the patient had an acute episode of transient left arm ischemia. To prevent future episodes of embolization with potentially greater morbidity, we prepared the patient for urgent left ventricular thrombectomy. Under general anesthesia, a median sternotomy incision was made. No obvious inflammatory changes were visible in the pericardium. Cardiopulmonary bypass was established, and the patient was cooled to 28°C. The aorta was cross-clamped and blood cardioplegia was delivered. A 1-cm transverse incision was made in the ascending aorta, the aortic leaflets were retracted, and a 4-mm 30-degree endoscope was advanced into the left ventricle (Fig 1). The thrombus was visualized at the apex of the left ventricle (Fig 2A) and was then removed through the aortotomy with endoscopic grasping forceps. Complete clot removal was confirmed by video-assisted visualization (Fig 2B) and by intraoperative transesophageal echocardiography. There was no evidence of damage to the papillary muscles or the aortic valve leaflets. Total cross-clamp time was 81 minutes. Specimens sent for pathologic evaluation included the thrombus, the right atrial appendage, and an endocardial biopsy sample.

View larger version (52K): [in this window] [in a new window]   Fig 1. A transverse incision was made in the ascending aorta, the aortic leaflets were retracted, and a 4-mm, 30-degree endoscope was advanced into the left ventricle. (LV = left ventricular.)

View larger version (62K): [in this window] [in a new window]   Fig 2. (A) The thrombus was visualized at the apex of the left ventricle. (B) Complete clot removal was confirmed by video-assisted visualization.

	Comment

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Video-assisted cardioscopy allows visualization and magnification of inaccessible intracardiac structures while avoiding vigorous cardiac manipulation and extended incisions [3]. Endoscopic visualization of remote anatomic structures has facilitated numerous other congenital open heart operations [3, 4]. We describe a pediatric application of VAC by which a thrombus in the left ventricle was assessed and removed, avoiding the morbidity of a left ventriculotomy. Video-assisted thoracoscopic surgery has been employed to improve anatomic visualization within the pleural space and to reduce chest wall trauma. Pediatric video-assisted thoracic surgical techniques include ligation of the patent ductus arteriosus, vascular ring division, thoracic duct ligation, interruption of arterial and venous collaterals, epicardial pacemaker lead placement, and pericardial window [4]. Video-assisted cardioscopy during open cardiac repairs has been achieved by employing adapted video systems used for extracardiac video-assisted thoracic surgical procedures.

The videoscopes developed for congenital heart surgery have a 7-cm working length and 2.7- or 4.0-mm diameters. Cameras providing 4x magnification are coupled with 30- to 70-degree face angles (Smith and Nephew, Dyonics, Inc, Andover, MA). The videoscope path is determined by the cardiac anatomy and the structures to be visualized. This path is planned to minimize additional cardiac incisions, operative field obstruction, and cardiac distortion.

Video-assisted cardioscopy has been employed in several operations including closure of ventricular septal defects, mitral valvuloplasty, and repositioning of transcatheter clamshell devices [4]. Video-assisted cardioscopy may also help localize residual ventricular septal defects. Furthermore, VAC could potentially facilitate transcatheter techniques by helping position devices and thus increase the precision of an otherwise blind technique [3].

Potential complications related to VAC are valve laceration, ventricular or atrial wall perforation, and conduction system contusion [3]. We have not encountered these complications in our experience. Cardiopulmonary bypass or aortic cross-clamp times may need to be extended to allow extra time to achieve optimal visualization.

Therapeutic modalities for the treatment of left ventricular thrombus remain controversial. Previously described approaches include anticoagulation and thrombus removal via ventriculotomy. Video-assisted cardioscopy permits thrombus removal with minimal ventricular trauma. This facilitates more rapid recovery of the myocardium from the inflammatory process without the additional injury of a ventriculotomy. Further studies are required to evaluate the range of potential applications of VAC. This case represents an additional example of how minimally invasive surgical techniques can be applied to minimize surgical trauma. We have used this particular approach to treat a variety of lesions of the mitral valve, left ventricle, left ventricular outflow tract, aortic valve, and ascending aorta. We now often modify this approach by limiting the length of the skin incision and only dividing the manubrium; a dual-stage venous cannula and venting through the dome of the left atrium facilitate this limited incision. The combination of VAC and minimally invasive cardiac surgery allows minimally traumatic access to lesions of the left ventricular outflow tract without compromising visualization. As instrumentation and technology improve, additional applications will develop.

	Acknowledgments

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Figure 1 was prepared by Jeffrey A. White, MS.

	References

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1. Van Dam J., Basilico F.C., Nesto R.W. Echocardiography in acute myocarditis associated with left ventricular thrombus formation and systemic embolization. J Ultrasound Med 1990;9:599-602.[Medline]
2. Lew A.S., Federman J., Harper R.W. Operative removal of mobile pedunculated left ventricular thrombus detected by two dimensional echocardiography. Am J Cardiol 1983;52:1148-1149.[Medline]
3. Burke R.P., Michielon G., Wernovsky G. Video-assisted cardioscopy in congenital heart operations. Ann Thorac Surg 1994;58:864-868.[Abstract/Free Full Text]
4. Burke R.P. Thoracoscopy in the management of pediatric congenital heart disease. Current review of laparoscopy. Philadelphia, PA: Current Medicine, 1995:157-165.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jeffrey P. Jacobs Redmond P. Burke Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mazza, I. L. Articles by Burke, R. P. Search for Related Content PubMed PubMed Citation Articles by Mazza, I. L. Articles by Burke, R. P.