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Ann Thorac Surg 1999;68:1063-1065
© 1999 The Society of Thoracic Surgeons

Case Reports

Transaortic video-assisted removal of a left ventricular thrombus

Takuro Tsukube, MDa, Masayoshi Okada, MDa, Yoshio Ootaki, MDa, Yoshihiko Tsuji, MDa, Chojiro Yamashita, MDa

a Department of Surgery, Division II, Kobe University School of Medicine, Kobe, Japan

Address reprint requests to Dr Tsukube, Department of Surgery, Division II, Kobe University School of Medicine, 7-5-1 Kusunoki-cho, Chuou-ku, Kobe, Japan 650-0017
e-mail: ttsukube{at}med.kobe-u.ac.jp


   Abstract
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 Abstract
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 References
 
A mobile and pedunculated left ventricular thrombus was developed after acute myocardial infarction in a 59-year-old man, and was successfully removed surgically through the aortic valve using a video-assisted thoracoscope. Transaortic video-assisted thoracoscopy greatly facilitated exposure of the interior of the left ventricle and preserved left ventricular function by avoiding ventriculotomy.


   Introduction
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 Abstract
 Introduction
Comment
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Thrombus formation in the left ventricular cavity is a common complication of acute myocardial infarction. Mobile and pedunculated thrombi are rare compared with mural thrombi, but have a significantly higher risk of embolism, so surgical excision is generally indicated to prevent life-threatening emboli [1]. We performed transaortic video-assisted excision of a mobile and pedunculated left ventricular thrombus in order to preserve left ventricular function after acute myocardial infarction by avoiding ventriculotomy. This article reports the first video-assisted removal of a left ventricular thrombus in a patient with acute myocardial infarction.

A 59-year-old man was admitted elsewhere with chest pain, a marked rise in myocardial enzymes, and ST segment changes in the anterior chest leads, suggesting an acute anterior infarction. He was transferred to our hospital and received intravenous heparin. No left ventricular thrombus was seen on the first echocardiogram. Emergency coronary angiogram demonstrated the occlusion of the midportion of the left anterior descending artery. Left ventriculogram showed akinesis of the anterior and septal walls of the left ventricle, with an ejection fraction of 35%. Percutaneous transluminal coronary angioplasty was performed, with subsequent placement of an intracoronary stent, after which remained dilated. Anticoagulation was given with intravenous heparin for 3 days, to achieve a partial thromboplastin time of twice normal. Nevertheless, 3 days later, echocardiogram showed akinesis of the anterior wall, good contraction of the posterolateral and inferior walls, and a large mural thrombus (2.5 x 2 cm in diameter) in the left ventricular apex. Ten days later, the thrombus was mobile and protruded into the left ventricle on transesophageal echocardiogram (Fig 1). Two days later (12 days after the onset of acute myocardial infarction), the left ventricular thrombus was safely removed surgically.



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  		Fig 1. Two-dimensional transesophageal echocardiogram showing a mobile and pedunculated thrombus in the left ventricular cavity. (LV = left ventricle; LA = left atrium; RV = right ventricle.

 
After midline sternotomy, bicaval and ascending aortic cannulation were accomplished and total cardiopulmonary bypass was initiated with systemic cooling to 30°C. A transaortic approach was chosen to avoid a ventricular incision with its potential complications. After cardioplegic arrest was achieved, a transverse incision was made in the ascending aorta. Using standard videothoracoscopic equipment, a viewing scope that allowed simultaneous visualization and thrombectomy was passed through the aortic valve and into the left ventricle. A thrombus was seen arising from the endocardial surface at the anterior septum (Fig 2). The stalk of the thrombus was easily grasped, and all of the residual thrombus was easily removed under guidance of the videothoracoscope. Intraoperative transesophageal echocardiogram demonstrated no residual mass. The thrombus measured 2.0 x 2.0 cm in diameter.



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  		Fig 2. Interior of the left ventricle viewed through the video-assisted thoracoscope introduced via the ascending aorta showing thrombus attached to the apex. (T = thrombus.)

 
The postoperative course was uncomplicated, and warfarin therapy was started on the second day after surgery and continued to achieve an international normalized ratio of 2.5 to 3. Echocardiogram on the 14th day after surgery showed no evidence of recurrent thrombus formation.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Left ventricular thrombus is a common complication of acute myocardial infarction, especially that involving the anterior and apical walls, appearing in 33% to 68% of autopsy patients or 20% to 40% of two-dimensional echocardiographic studies [2]. The vast majority of these thrombi are mural, flat, and immobile, and have a low risk of embolism. Mobile, pedunculated thrombi are rare in comparison with mural thrombi, however, they have a significantly higher risk of embolism. Although anticoagulant treatment may cause some left ventricular thrombi to resolve and the risk of systemic emboli may be reduced significantly, recurrent embolization during anticoagulant treatment has been reported. Moreover, the outcome of patients with recurrent emboli from mobile, pedunculated thrombi who are not treated surgically is generally very poor compared with that of the limited number who undergo surgery.

However, emergency left ventricular thrombectomy carries all the risks of surgery for patients with acute myocardial infarction along with the added problem of closing the friable ventriculotomy. Making an incision in the acutely infarcted ventricular wall may cause further deterioration of left ventricular function, especially if the left ventricular function is already poor. Also, the fragile ventricular wall may increase the risk of bleeding, and the ventriculotomy may potentially induce ventricular arrhythmia and poor function.

In our case, we reached the left ventricular cavity through the aortic valve using videothorascopic equipment under cardioplegic arrest and excised the left ventricular thrombus. Successful video-assisted excision of a left ventricular papillary fibroelastoma through the aortic valve was previously reported [3], but to our knowledge, this is the first case of transaortic video-assisted left ventricular thrombectomy. Trans-left atrial appendage and mitral valve approach also provide a good visualization of the left ventricle [4], and this approach should be recommended when the aortic valve or the ascending aorta has severe sclerotic changes. With careful myocardial protection and emptying of the left ventricle via a vent, this technique provides a good operative field and an excellent outcome, especially in patients with poor left ventricular function.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Smolinsky A., Ziskind Z., Mohr R., Goor D.A., Motro M. Left ventricular thrombectomy in the early postinfarction period. Thorax 1990;45:548-551.[Abstract/Free Full Text]
  2. Nili M., Deviri E., Jortner R., Strasberg B., Levy M.J. Surgical removal of a mobile, pedunculated left ventricular thrombus. Ann Thorac Surg 1988;46:396-400.[Abstract]
  3. Allen K.B., Goldin M., Mitra R. Transaortic video-assisted excision of a left ventricular papillary fibroelastoma. J Thorac Cardiovasc Surg 1996;112:199-201.[Free Full Text]
  4. Espada R., Talwalker N.G., Wilcox G., Kleiman N.S., Verani M.S. Visualization of ventricular fibroelastoma with a video-assisted thoracoscope. Ann Thorac Surg 1997;63:221-223.[Abstract/Free Full Text]
Accepted for publication January 28, 1999.




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This Article
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Masayoshi Okada
Chojiro Yamashita
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