Ann Thorac Surg 2005;79:e11-e12
© 2005 The Society of Thoracic Surgeons
How to do it
Management of Left Atrial Endocardium After Extensive Thrombectomy
Cheong Lim, MDa,
Won-Hee Rhyu, MDa,
Young Lee, MDb,
Joong Haeng Choh, MD, FACSa,*
a Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul, Korea
b Department of Thoracic and Cardiovascular Surgery, Chungnam University Hospital, Daejun, Korea
Accepted for publication September 2, 2004.
* Address reprint requests to Dr Choh, Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, 300 Kumi-dong, Bundang-ku, Seongnam-shi, Kyungki-do 463-707, South Korea (E-mail: jhcspc{at}snubh.org).
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Abstract
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Thrombosis at the left atrium is a common phenomenon in patients with chronic mitral valve disease and atrial fibrillation. When thrombus organizes and evolves into chronic phase, clean thrombectomy can become a challenge during heart surgery because of dense adhesions and the lack of clean cleavage plane. Leaving residual thrombotic material or roughened endocardial surface after thrombectomy could be a potential source for further thrombosis and a nidus for thromboembolism. We recently managed such a patient successfully using extensive thrombectomy and endocardial coverage with a fresh autologous pericardial patch.
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Introduction
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Intracardiac thrombosis develops most commonly at the left atrial appendage, but it can sometimes involve extensive area of the left atrial surface. When thrombotic material undergoes organization and the thrombotic process evolves into chronic phase, clean thrombectomy becomes a surgical challenge because of dense adhesions and the lack of a clean cleavage plane. Furthermore, leaving residual thrombotic material on the roughened endocardial surface after the thrombectomy can be a potential nidus for thromboembolic phenomenon during the postoperative period [1].
We recently managed such a patient with the extensive left atrial thrombectomy using the following technique at the time of mitral valve replacement, tricuspid repair, and modified maze procedure.
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Technique
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A 45-year-old man was admitted with progressive dyspnea and recurrent episodes of pulmonary edema. Medical history revealed rheumatic valvular heart disease and chronic exertional dyspnea. Echocardiogram and cardiac catheterization revealed severe mitral stenosis with regurgitation, a markedly enlarged left atrium, severe tricuspid regurgitation, atrial fibrillation, and a thrombus in the left atrial appendage. A broad area at the base of the left atrium was covered with thrombus-like material. Coronary arteries were normal. Pulmonary arterial systolic pressure was 51 mm Hg.
Under cardiopulmonary bypass and cardioplegic arrest, the mitral valve was replaced with a mechanical valve. Tricuspid valve repair was done using an annuloplasty ring. Simultaneous modified Cox-maze III procedure was performed using a microwave device (Microwave Ablation System with FLEX 4 probe; AFx Inc, Fremont, CA) with the lesions encircling the right and left pulmonary veins. These lesions were extended to the posterior mitral annulus and left atrial appendage. Right-sided lesions were also created for the isthmus and superior and inferior vena cavae.
The left atrium was markedly enlarged, and a large number of both fresh and organized clots were noted in the left atrium. These organized clots were densely adhered with severely fibrotic changes, covering the broad surface of the left atrium. Extensive thrombectomy was performed, and the left atrial appendage was closed with a pursestring suture. After removal of the thrombotic material, many residual pieces were still left on the left atrial endocardium, and areas of roughened surface with fibrotic residues of organized thrombus were noted.
Complete clean thrombectomy did not appear to be technically feasible. Excision of the excessive left atrial tissue with the irregular, roughened surface was considered; however, it was not deemed to be feasible because the area was too large and irregular, and also the involved area was too close to the orifices of pulmonary veins. Therefore, we elected to cover the area with an appropriately fashioned, 4 cm by 8 cm autologous pericardium patch, sewn over the area of endocardial irregularity using a running 4-0 polypropylene suture. The pericardium was cut according to the geography of the rough area, resulting in complete coverage of the problematic area with a clean pericardial surface (Fig 1).
The patient's postoperative course was smooth, without complication. He remained in normal sinus rhythm and showed gratifying symptomatic improvement of his heart failure. He was maintained on warfarin therapy. There was no echocardiographic evidence of new thrombus formation in the left atrium (Fig 2).
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Fig 2. Late follow-up echocardiography showing pericardial patch (arrow). (LA = left atrium; LV = left ventricle; RV = right ventricle.)
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Comment
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Application of pericardium in cardiac surgery is a well-known technique [2]. It has been used as a patch material in atrial or ventricular septal defects or reconstruction of a new pulmonary artery in the repair of transposition of great arteries. In the area of adult cardiac surgery, it has been used in the reconstruction of the mitral annulus after extensive debridement for infected tissue in cases of bacterial endocarditis [3, 4] and after excision and debridement of mitral valves with severe calcifications extending into atrial and ventricular structures [5–7].
In patients with chronic mitral valve disease and atrial fibrillation, formation of thrombus in the left atrium is a well-known phenomenon. If thrombus in the left atrium is left, it can organize and undergo chronic fibrotic or calcific changes and adhere densely to the atrial wall. At this stage, excision or clean removal of the thrombotic material from the atrial surface can be technically difficult.
When thrombus is encountered in the left atrium at the time of a mitral valve surgery, the surgeon would generally remove the thrombotic material and attempt to remove the source of potential thrombus formation. The left atrial appendage, the most frequent source of thrombus formation, is generally amputated or ligated by a pursestring suture. If densely adhered, organized thrombus is removed from the surface of left atrium; the remaining surface can be extremely irregular with residual thrombus, calcification, and fibrotic changes. This area can be a source of new embolic phenomenon or a nidus for new thrombus formation and should be surgically eliminated. Excising a part of the markedly enlarged left atrium in mitral surgery is a known technique, but the excision should not include critical areas such as the area close to pulmonary veins or mitral annulus.
In our case, excision of the irregular surface of the left atrium was not an option because the area was too large to sacrifice, and part of the involved area was too close to the pulmonary veins. Covering the area with autologous pericardium was an attractive option because of its ease to fashion in any shape necessary, its pliability, and the clean surface it can provide after the complete coverage of the problematic area.
We believe the described technique will be an attractive technical alternative for a mitral valve surgeon who may face similar circumstances with extensive, chronic, organized thrombosis on the left atrial surface in which clean thrombectomy is technically difficult.
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References
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- Yamaji K, Fujimoto S, Yutani C, Hashimoto T, Nakamura S. Is the site of thrombus formation in the left atrial appendage associated with the risk of cerebral embolism? Cardiology 2002;97:104-110.[Medline]
- David TE. The use of pericardium in acquired heart disease: a review article J Heart Valve Dis 1998;7:13-18.[Medline]
- Kunitomo R, Hara M, Utoh J, Sakaguchi H, Uemura S, Kitamura N. Patch reconstruction of the mitral annulus for active infective endocarditis with annular abscess Ann Thorac Cardiovasc Surg 2001;7:52-55.[Medline]
- Inoue T, Otaki M, Wakaki N, Oku H. Extensive left atrial endoatriectomy for infective endocarditis J Heart Valve Dis 2002;11:357-359.[Medline]
- Feindel CM, Tufail Z, David TE, Ivanov J, Armstrong S. Mitral valve surgery in patients with extensive calcification of the mitral annulus J Thorac Cardiovasc Surg 2003;126:777-782.[Abstract/Free Full Text]
- Fasol R, Mahdjoobian K, Joubert-Hubner E. Mitral repair in patients with severely calcified annulus: feasibility, surgery and results J Heart Valve Dis 2002;11:153-159.[Medline]
- Ng CK, Punzengruber C, Pachinger O, et al. Valve repair in mitral regurgitation complicated by severe annulus calcification Ann Thorac Surg 2000;70:53-58.[Abstract/Free Full Text]
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Abstract
Introduction
