Ann Thorac Surg 2001;72:953-954
© 2001 The Society of Thoracic Surgeons
How to do it
Simplified method of left ventricular thrombectomy
Gerald L. Early, MDa,
Michael Ballenger, RN, NPa,
Hamner Hannah, III, MDa,
Shauna R. Roberts, MDa
a Division of Cardiothoracic Surgery, Department of Surgery, Kansas University Medical Center, Kansas City, Kansas, USA
Accepted for publication August 16, 2000.
Address reprint requests to Dr Early, 1228 E Rusholme, Ste 110, Davenport, IA 52803
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Abstract
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Postinfarction left ventricular thrombi are at risk for embolization with resultant injury. Surgical removal is recommended especially if they are pedunculated or mobile. We describe an easily applied transatrial method that can allow avoidance of a ventriculotomy.
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Introduction
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Thrombus formation on the left ventricular endocardial surface is common following acute myocardial infarction, especially if there is a large anterior infarction and congestive heart failure is present [1, 2]. Most often these thrombi are smooth, conform to the cavity shape and are relatively stable. Rarely they may be mobile or pedunculated. In that situation, they are at greater risk of embolization [3], and thrombectomy is recommended [4]. This article reports a very quick and simple method of performing ventricular thrombectomy while avoiding ventriculotomy.
A 64-year-old woman was admitted through the emergency department with an acute anterior myocardial infarction. She was treated with intravenous thrombolytic therapy and demonstrated a marked rise in myocardial enzymes. No left ventricular thrombus was seen on the first echocardiogram, and a cardiac catheterization was done on the same day. Data obtained included elevated pulmonary artery and left ventricular end diastolic pressures, and an ejection fraction of 25%. The anterior and apical portions of the left ventricle were akinetic and, in the apex, there was an irregular mobile and pedunculated thrombus (Fig 1). She had significant stenosis involving her proximal left anterior descending, obtuse marginal, and right coronary arteries. Intense medical management was pursued to obtain hemodynamic stability and clearance of pulmonary edema. Subsequently, she was taken to the operating room for thrombectomy and coronary artery bypass surgery. Repeat preoperative, as well as intraoperative, echocardiography verified decreased contractility and persistence of the apical thrombus.
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Technique
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A midline sternotomy was performed, ascending aortic and bicaval cannulation completed, and cardiopulmonary bypass with moderate hypothermia was instituted. Cold blood cardioplegia was delivered in both an antegrade and retrograde fashion, and myocardial temperature was monitored. A left atriotomy was performed and an illuminated retractor introduced. This retractor (SaphLITE, Genzyme Corporation, Tucker, GA) was designed for saphenous vein harvest through limited incisions. The tip of the retractor was easily passed across the mitral annulus into the left ventricle, and good visualization was obtained. The thrombus, which was approximately 2 cm in diameter, was removed with a ring forceps, and the ventricular cavity was irrigated. A catheter was placed across the mitral valve into the left ventricle, and the atriotomy was partially closed. Coronary artery grafts were then placed utilizing the left internal thoracic artery to graft the left anterior descending, and separate vein grafts to the obtuse marginal and posterior descending arteries. Proximal anastamoses were performed after removal of the aortic cross-clamp with the aid of a partial occlusion clamp. After warming, she was weaned from cardiopulmonary bypass with dopamine support and with a marked improvement in her cardiac index.
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Comment
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Mobile and pedunculated thrombi are rare [3] but are much more threatening because of a high risk of embolization. It has been suggested that they be surgically removed [4], and this has usually been done by ventriculotomy [5]. A left ventriculotomy entails some inherent risks, especially in the presence of an acute myocardial infarction. However, recently, a technique was described which avoided ventriculotomy by using a videoscope passed through an aortotomy [6].
The method that we report is very quickly applied and allowed us to easily perform the thrombectomy under direct vision, however, organized thrombi adherent to ventricular trabeculae might be difficult to remove by this method. The larger mitral annulus may make removal simpler than through the aorta, it does allow left ventricular venting to be accomplished directly, and it permits access to the mitral valve if needed. This technique, utilizing an illuminated retractor, allows ease of thrombectomy, avoids ventriculotomy, and gives the surgeon an additional access route.
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References
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Jordan R.A., Miller R.D., Edwards J.E., Parker R.L. Thromboembolism in acute and in healed myocardial infarction: I. Intracardiac mural thrombosis. Circulation 1952;6:1-6.[Medline]
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Visser C.A., Kan G., Lie K.I., Durrer D. Left ventricular thrombus following acute myocardial infarction: a prospective serial echocardiographic study of 96 patients. Eur Heart J 1983;4:333-337.[Abstract/Free Full Text]
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Haugland J.M., Asinger R.W., Mikell F.L., Elsperger J., Hodges M. Embolic potential of left ventricular thrombi detected by two-dimensional echocardiography. Circulation 1984;70:588-598.[Abstract/Free Full Text]
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Hartman R.B., Harrison E.E., Pupello D.F., Vijayanagar R., Sbar S.S. Characteristics of left ventricular thrombus resulting in perioperative embolism. J Thorac Cardiovasc Surg 1983;86:706-709.[Abstract]
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Nili M., Deviri E., Jortner R., Strasberg B., Levy M. Surgical removal of a mobile, pedunculated left ventricular thrombus: report of 4 cases. Ann Thorac Surg 1988;46:396-400.[Abstract]
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Tsukube T., Okada M., Ootaki Y., Tsujiy Y., Yamashita C. Transaortic video-assisted removal of a left ventricular thrombus. Ann Thorac Surg 1999;68:1063-1065.[Abstract/Free Full Text]
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Abstract
Introduction
