Abstract
Background
Left ventricular thrombi may complicate acute myocardial infarction, and anticoagulation is the mainstay of management. Surgical thrombectomy may be considered in some patients with a perceived high risk for thromboembolism if there is another indication for urgent cardiac surgery.
Case Summary
A 43-year-old diabetic man presented with a non–ST-segment elevation myocardial infarction and an acute left ventricular thrombus. He had a transaortic thrombectomy and coronary artery bypass graft.
Discussion
The usual approach for surgical thrombectomy is left ventriculotomy. This however may cause deterioration of left ventricular function. A left atrial approach has also been described but access may be challenging. A video-assisted transaortic left ventriculoscopy combines excellent visualization provided by the endoscope and avoidance of a left ventriculotomy.
Take-Home Messages
Surgical thrombectomy may be beneficial in a select group of patients with acute left ventricular thrombus. A video-assisted transaortic approach provides excellent access and visualization in these patients.
Key words: anticoagulation, coronary artery bypass, thrombus
Graphical Abstract
Patient Presentation
A 43-year-old man with a 9-month history of exertional chest tightness presented with acute chest pain. Examination findings were unremarkable. Electrocardiogram showed T-wave inversion in the anterior and lateral leads, and troponin was elevated.
Take-Home Messages
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Surgical thrombectomy may be beneficial in a select group of patients with acute left ventricular thrombus.
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A video-assisted transaortic approach provides excellent access and visualization in these patients.
Past Medical History
He was a recently diagnosed diabetic and suffered from hypertension and asthma.
Differential Diagnosis
A diagnosis of acute coronary syndrome was made. Other differentials considered included pericarditis, acute aortic syndrome, and pulmonary embolus.
Investigations
Invasive coronary angiography revealed a chronic total occlusion of the left circumflex and left anterior descending arteries and severe disease in the distal right coronary artery. Left ventriculogram showed localized apical akinesis and a large, mobile defect at the apex consistent with a thrombus (Figure 1A, Video 1). Transthoracic echocardiogram (TTE) showed good biventricular function and an 11-mm apical filling defect consistent with a thrombus (Figure 1B). The ventricular apex was not thinned out or aneurysmal.
Figure 1.
Preoperative Left Ventriculogram, Echocardiogram, and Intraoperative Images
(A) Left ventriculogram showing apical thrombus (black arrow). (B) Transthoracic echocardiogram showing thrombus at the apex of the left ventricle (white arrow). (C) Intraoperative photos showing thrombus within the left ventricle (white arrow). (D) Thrombus being removed at surgery.
He was referred for urgent coronary artery bypass grafting, and given the highly mobile nature of the thrombus, video-assisted surgical thrombectomy was also performed.
Surgical Technique
The setup was for a coronary artery bypass graft via a median sternotomy. After harvest of the left internal mammary artery, a pericardiotomy was done and the aorta and right atrium were cannulated for cardiopulmonary bypass. The aorta was cross clamped, and cold antegrade cardioplegia was delivered to arrest the heart.
A transverse aortotomy was performed in the proximal ascending aorta, and a 5-mm 0° scope (Karl Storz) was introduced via an aortotomy, advanced beyond the aortic valve and into the left ventricle, visualizing the thrombus at the apex of the left ventricle (Figures 1C and 1D, Video 1). Complete extraction of the thrombus was performed. The left ventricular (LV) cavity was washed out with saline. The aortotomy was closed, and the bypass grafts were completed in standard fashion. Intraoperative transesophageal echocardiography was used to visualize the thrombus and confirm complete removal at the conclusion of the procedure.
Outcome
The patient was discharged home after an uneventful recovery on the fifth postoperative day. He was discharged home on 75 mg of aspirin and 60 mg of edoxaban daily. A 2-month follow-up echocardiogram showed good LV function and no evidence of thrombus recurrence.
Discussion
Risk factors for acute LV thrombus after a myocardial infarction include patients with an anterior ST-segment elevation myocardial infarction, large infarction area, and long delay between symptoms and reperfusion,1 and LV thrombus carries a significant risk of systemic thromboembolism.1
Identifying LV thrombus may be challenging. The standard modality is TTE.1 TTE however poorly images the apex of the left ventricle due to poor tissue characterization and definition, so in up to 46% of cases, TTE remain inconclusive for diagnosis of LV thrombus.2 Contrast echocardiography may double the sensitivity of TTE by improving border definition and tissue characterization.1 Transesophageal echocardiography has similar limitations to TTE.2 Cardiac magnetic resonance is the gold standard for diagnosis of LV thrombus.1
Anticoagulation is the mainstay of treating LV thrombi1; historically, warfarin has been the agent of choice, but direct oral anticoagulants have emerged as an alternative in managing these patients. A recent randomized controlled trial of rivaroxaban and warfarin showed that rivaroxaban was as effective and safe as warfarin in resolving postmyocardial infarction LV thrombus at 3 months.3 Recent American Heart Association (AHA) guidelines suggest a duration of 3 to 6 months guided by repeat imaging.1
The role of surgical thrombectomy is still debated with most of the data consisting of case reports and series, thus highlighting the need to balance the risks of surgery vs the benefit of successfully removing all thrombus. The 2022 AHA guidelines do not recommend surgical thrombectomy if there is no other indication for cardiac surgery but do suggest that in rare cases, such as inability to tolerate anticoagulation, cardioembolic stroke despite anticoagulation, and high risk of embolization, surgery may be considered.1 It does not define which thrombus should be deemed high risk, but some authors in published case reports describe thrombus characteristics (eg, mobility independent of myocardium, large, protruding) as increasing the risk for embolization.4, 5, 6 Surgical removal does carry the advantage of making a firm diagnosis and removing all clots, thus removing the risk of embolization. In these circumstances, acute thrombi may be more amenable for surgical thrombectomy because the clot is not firmly adherent to the myocardium and there is a higher likelihood of removing all thrombi without unnecessarily prolonging surgery time. There was significant concern about the embolic potential of the thrombus in this patient, given its size mobility and limited ventricular attachment; the multidisciplinary team therefore recommended surgical thrombectomy at the time of bypass grafting. The decision of surgical thrombectomy for chronic clots is more nuanced because these clots tend to be morbidly adherent to the myocardium, are less amenable to alternative approaches apart from a ventriculotomy, and are likely to prolong surgery time. The risk vs benefits in these cases may be determined by a multidisciplinary team on a patient-to-patient basis.
There are several approaches to surgical thrombectomy; however, historically, a left ventriculotomy was common.7 This approach gives direct visualization of the thrombus and facilitates complete removal. Due to concerns about a further deterioration in LV function,8 alternative approaches such as transmitral via a left atriotomy and transaortic approaches have been devised.5 Both approaches avoid ventriculotomy, and when aided by a telescope, may give excellent visualization of the thrombus; however, overall access may be restricted. When the thrombus is located on an aneurysmal or thinned out apex, ventriculotomy will not influence LV function.
The role of postoperative anticoagulation after surgical LV thrombectomy is unclear. In patients treated with anticoagulation alone, AHA guidelines recommend repeat imaging at 3 months and stopping anticoagulation if the thrombus has resolved.1 Because surgical thrombectomy completely removes the thrombus, continuing anticoagulation would seem inappropriate if the same reasoning is applied. The same guidelines however also state that the risk of rethrombosis is highest within the first 3 months after an acute myocardial infarction, especially if the LV function and wall motion abnormalities have not improved. Whether anticoagulation would be necessary after surgical thrombectomy, and the duration, is still an unanswered question. Where hemodynamic or surgical risk factors for thrombus formation persist, it is reasonable to continue anticoagulation until such risks are mitigated. Until there are more data, local heart teams may need to determine this on a patient-to-patient basis.
There have been a few case reports of a video-assisted transaortic approach to removal of LV thrombus.9,10 The transaortic video-assisted approach as shown in Video 1, avoids a ventriculotomy, provides excellent visualization of the thrombus and direct removal, and is especially suited for acute thrombi.
Summary
Surgical thrombectomy may be beneficial in select patients with acute coronary syndromes complicated by acute LV thrombus. Video-assisted transaortic LV thrombectomy is a reasonable approach to removing these thrombi. More research is required to define the role and duration of anticoagulation after complete surgical thrombectomy.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For a supplemental video, please see the online version of this paper.
Appendix
Ventriculogram and Intraoperative Video Showing Video-Assisted Transaortic Surgical Thrombectomy
LV = left ventricular.
References
- 1.Levine G.N., McEvoy J.W., Fang J.C., et al. Management of patients at risk for and with left ventricular thrombus: a scientific statement from the American Heart Association. Circulation. 2022;146(15):e205–e223. doi: 10.1161/CIR.0000000000001092. [DOI] [PubMed] [Google Scholar]
- 2.Delewi R., Zijlstra F., Piek J.J. Left ventricular thrombus formation after acute myocardial infarction. Heart. 2012;98(23):1743–1749. doi: 10.1136/heartjnl-2012-301962. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Mansouri P., Jazi Z.A., Mansouri M.H., et al. Evaluation of the efficacy and safety of rivaroxaban compared to warfarin in patients with left ventricular apical thrombus: a randomized clinical trial. Thromb J. 2024;22(1):66. doi: 10.1186/s12959-024-00632-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Pasli S., Kamler M., Malik R., Easo J. Complicated massive left ventricular thrombus and surgical treatment. Am J Case Rep. 2022;23 doi: 10.12659/AJCR.937341. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Takahashi D., Wada H., Ogita M., et al. Successful surgical transmitral removal of left ventricular thrombus after acute anterior myocardial infarction without left ventriculotomy. J Cardiol Cases. 2021;23(1):24–26. doi: 10.1016/j.jccase.2020.08.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Suzuki K., Sakamoto S.I., Hiromoto A., et al. Case of left ventricular thrombus managed with thrombectomy with left ventricular reconstruction in a patient who had coronavirus disease 2019 infection. J Cardiothorac Surg. 2023;18(1):8. doi: 10.1186/s13019-023-02108-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Nili M., Deviri E., Jortner R., Strasberg B., Levy M.J. Surgical removal of a mobile, pedunculated left ventricular thrombus: report of 4 cases. Ann Thorac Surg. 1988;46(4):396–400. doi: 10.1016/s0003-4975(10)64651-6. [DOI] [PubMed] [Google Scholar]
- 8.Tanaka D., Unai S., Diehl J.T., Hirose H. Surgical removal of a large mobile left ventricular thrombus via left atriotomy. World J Clin Cases. 2014;2(2):32–35. doi: 10.12998/wjcc.v2.i2.32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Cruz Rodriguez J.B., Okajima K., Greenberg B.H. Management of left ventricular thrombus: a narrative review. Ann Transl Med. 2021;9(6):520. doi: 10.21037/atm-20-7839. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Eranki A., Villanueva C., Collins N., Seah P. Video assisted, transaortic removal of left ventricular thrombus during concurrent cardiac surgery: a case report. J Cardiothorac Surg. 2021;16(1):242. doi: 10.1186/s13019-021-01626-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Ventriculogram and Intraoperative Video Showing Video-Assisted Transaortic Surgical Thrombectomy
LV = left ventricular.