Logo American Journal of Case Reports

Call: 1.631.629.4328
Mon-Fri 10 am - 2 pm EST

Contact Us

Logo American Journal of Case Reports Logo American Journal of Case Reports Logo American Journal of Case Reports

04 October 2022: Articles  Germany

Complicated Massive Left Ventricular Thrombus and Surgical Treatment

Challenging differential diagnosis, Management of emergency care, Rare disease

Sedat Pasli1ABEF*, Markus Kamler1ADE, Rizwan Malik1CD, Jerry Easo1AE

DOI: 10.12659/AJCR.937341

Am J Case Rep 2022; 23:e937341

0 Comments

Abstract

BACKGROUND: Left ventricular thrombus formation is a serious complication of cardiac diseases and may result in acute embolic events. Early diagnosis and prompt treatment are crucial steps in preventing complications. There is a lack of consensus when it comes to therapy recommendations such as treatment with anticoagulation, thrombolysis, or surgical thrombectomy.

CASE REPORT: A 74-year-old woman presented with acute peripheral ischemia in the left and right lower limbs. After running a diagnostic workup, we found a history of fatigue and dyspnea in the preceding 2 weeks; and an echocardiographic examination revealed a large floating mass in the left ventricle with a severely reduced LV ejection fraction of 10-15%. Coronary heart disease was diagnosed with stenosis of the circumflex artery and posterior branch of the right coronary artery, but not necessitating acute treatment. The decision to operate on our patient was based on the acute situation and mobile form of the thrombi as to prevent further thromboembolic complications, and the surgical procedure was performed via a median sternotomy using a left ventricular apical approach due to the size and deep embedment in the ventricular trabeculae.

CONCLUSIONS: To date there is no standardized therapy in the guidelines for treatment of LV thrombi. Surgical thrombectomy can be performed in patients with mobile and protruding thrombi. In such cases surgery should be performed immediately due to the high risk of systemic embolism.

Keywords: Heart Ventricles, thromboembolism, Thrombosis

Background

Left ventricular thrombus formation is a serious complication of cardiogenic diseases such as myocarditis or myocardial infarction, followed by inflammatory reactions of the myocardium resulting in excessive coagulopathy. Thrombi in the cavities of the heart often result in acute embolic events that can have cerebral effects, or systemic embolic events with increased morbidity and mortality when left untreated [1–4], thus necessitating a clearly defined stringent treatment algorithm to prevent serious complications of left ventricular thrombus. We report a rare case of a 74-year-old woman with a combination of pathologies due to a massive thrombus in the left ventricle including acute peripheral ischemia, cardiac decompensation, and combined valve pathology, treated successfully via a left ventricular apical approach.

Case Report

A 74-year-old woman presented with acute peripheral ischemia in the left and right lower limbs, necessitating emergent thromboembolectomy followed by extensive fasciotomy due to acute ischemia. Diagnostic workup revealed a history of fatigue and dyspnea in the preceding 2 weeks. Echocardiographic examination demonstrated a large mass of 4.5×4.2 cm in the left ventricle, in parts adhering to the apex and septum, floating in other parts (Figures 1, 2). LV ejection fraction was severely reduced to 10–15%, the apical portions of the left ventricle were akinetic, and the end-diastolic ventricular diameter was 65 mm. Mild mitral and tricuspid regurgitation was noted. Pulmonary artery pressure was elevated at 40 mmHg and coronary angiography revealed 2-vessel disease with 60% circumflex stenosis and 80% stenosis of the small right posterior branch without need for acute therapy (Figures 3, 4). A PCI treatment of the marginal branch stenosis was planned for a later intervention.

An immediate decision for emergent surgical embolectomy led to referral, and upon admission the patient presented with cardiogenic shock requiring inotrope medication in high doses. The patient presented with troponin levels of 517 µg/L and CK-Mb levels of 73 U/L, postulating a possible prior myocar-dial infarct as etiogenetic for thrombus formation.

The surgical procedure was performed via a median sternotomy. After establishment of extracorporeal circulation, cross clamp and antegrade cardioplegia with cold crystalloid solution was delivered via the aortic root for myocardial protection. After incision of the LV apex, a large 4.5×4.2 cm thrombus was found to be broadly attached to the septal and lateral wall, with thrombus deeply attached in the trabecular muscles. There was no need for coronary reconstruction via the anatomical approach. Thrombus age was approximately 10–14 days, with older and newer portions. Thorough and meticulous extraction was performed, cleaning and flushing of the ventricle was tedious, but the surgery was straight-forward and the postoperative course was without any complications.

In the postoperative echocardiographic examination, the left ventricle was observed to be completely free from thrombus, and decreased left ventricular contractility and akinesia at the apex remained identical to the preoperative function. Coagulation disorders were excluded by additional laboratory tests.

The histopathological examination demonstrated fresh thrombus material with typical stratification without endocardium parts. Postoperatively, the patient had an uneventful hospital stay. Lower limb extended fasciotomy and postischemic oedema were treated with vacuum therapy until secondary closure of the wound. She was transferred to her referring hospital on postoperative day 12.

Discussion

Left ventricular thrombus formation is a complication in patients with wall motion abnormalities, usually following myocardial infarction, dilated cardiomyopathy, or myocarditis. Syndromes resulting in hypercoagulopathy such as protein S and C deficiency and antiphospholipid syndrome have also been involved in LV thrombus formation in muscular dystrophies, Behcet’s disease, and Loeffler’s endocardial fibrosis, among others [5–7]. Reports show that LV thrombus increases the risk of peripheral embolization, as in our patient [1,8], particularly in patients with thrombus protrusion into the ventricular cavity and also in cases of increased mobility [9,10].

Early diagnosis and prompt treatment are crucial to prevent complications. Although echocardiography is the most frequently used diagnostic method, a study has shown that magnetic resonance imaging has the highest sensitivity and specificity for LV thrombus diagnosis in comparison with a transthoracic echocardiography [3]. Other reports show improved echo-cardiographic sensitivity to large protruding LV thrombi when the clinical indication was specifically for LV thrombus evaluation [11].

To date there is no standardized therapy in the guidelines for treatment of LV thrombi. Surgical thrombectomy, treatment with low molecular weight or unfractionated heparin, new oral anticoagulation therapy, and thrombolysis are various options with a wide spectrum of results. Several studies show a very high rate of systemic embolic complications after treatment with fibrinolytics, with consequent high risk of hemorrhagic events [7,12–14]. There have been few studies on the surgical treatment of LV thrombi and are mostly case reports or case series showing none of these patients to develop thromboembolism after surgical treatment [15,16]. The decision to operate on our patient was based on the mobility of the thrombi and to prevent further thromboembolic complications.

Due to several reasons, we decided to perform the surgical procedure via the left ventricular apex. The magnitude of the thrombus and the deep embedding in the trabeculae was deemed technically more challenging using a transmitral approach. The akinetic apex and the severely reduced left ventricular contractility supported the concept of a left ventricular approach, with the goal of reducing left ventricular dimension and thus possibly improving the left ventricular morphology. Alternative approaches such as via a left atriotomy [17,18] or through the aorta in concomitant aortic valve surgeries [19] have been described but were not implemented due to the above reasons.

Conclusions

Since there are no evidence-based guidelines for the treatment of LV thrombi, individual treatment options based on the risk of surgery, embolization, and bleeding must be considered. Surgical thrombectomy can be performed in patients with mobile and protruding thrombi. Surgery should be performed without delay due to the high risk of systemic embolism.

References:

1.. Haugland JM, Asinger RW, Mikell FL, Embolic potential of left ventricular thrombi detected by two-dimensional echocardiography: Circulation, 1984; 70; 588-98

2.. Stratton JR, Resnick AD, Increased embolic risk in patients with left ventricular thrombi: Circulation, 1987; 75; 1004-11

3.. Srichai MB, Junor C, Rodriguez LL, Clinical, imaging, and pathological characteristics of left ventricular thrombus: A comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation: Am Heart J, 2006; 152(1); 75-84

4.. Hartman RB, Harrison EE, Pupello DF, Characteristics of left ventricular thrombus resulting in perioperative embolism: J Thorac Cardiovasc Surg, 1983; 86; 706-9

5.. Wilensky RL, Jung SC, Thromboembolism in patients with decreased left ventricular function: Incidence, risk, and treatment: J Cardiovasc Risk, 1995; 2(2); 91-96

6.. Tilling L, Becher H, The vanishing vast ventricular thrombus: Eur J Echocardiogr, 2007; 8(1); 67-70

7.. Leick J, Szardien S, Liebetrau C, Mobile left ventricular thrombus in left ventricular dysfunction: Case report and review of literature: Clin Res Cardiol, 2013; 102(7); 479-84

8.. van Dantzig JM, Delemarre BJ, Bot H, Visser CA, Left ventricular thrombus in acute myocardial infarction: Eur Heart J, 1996; 17(11); 1640-45

9.. Ciaccheri M, Castelli G, Cecchi F, Lack of correlation between intracavitary thrombosis detected by cross sectional echocardiography and systemic emboli in patients with dilated cardiomyopathy: Br Heart J, 1989; 62(1); 26-29

10.. Fuster V, Halperin JL, Left ventricular thrombi and cerebral embolism: N Engl J Med, 1989; 320(6); 392-94

11.. Weinsaft JW, Kim HW, Crowley AL, LV thrombus detection by routine echocardiography: Insights into performance characteristics using delayed enhancement CMR: JACC Cardiovasc Imaging, 2011; 4(7); 702-12

12.. Mallory R, Balcezak T, Treatment of mobile left ventricular thrombus with low-molecular-weight heparin: N Engl J Med, 1999; 341(14); 1082-83

13.. Keren A, Goldberg S, Gottlieb S, Natural history of left ventricular thrombi: Their appearance and resolution in the post hospitalization period of acute myocardial infarction: J Am Coll Cardiol, 1990; 15(4); 790-800

14.. Sari I, Davutoglu V, Soydinc S, Fibrinolytic treatment in left ventricular mobile thrombi with low ejection fraction: Results and follow-up of seven cases: J Thromb Thrombolysis, 2008; 25; 293-96

15.. Lee JM, Park JJ, Jung HW, Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents: J Atheroscler Thromb, 2013; 20(1); 73-93

16.. Nili M, Deviri E, Jortner R, Surgical removal of a mobile, pedunculated left ventricular thrombus: Report of 4 cases: Ann Thorac Surg, 1988; 46(4); 396-400

17.. Tanaka D, Unai S, Diehl JT, Hirose H, Surgical removal of a large mobile left ventricular thrombus via left atriotomy: World J Clin Cases, 2014; 2(2); 32-35

18.. Early GL, Ballenger M, Hannah H, Roberts SR, Simplified method of left ventricular thrombectomy: Ann Thorac Surg, 2001; 72; 953-54

19.. Williamson C, Sheehan LB, Venesy DM, D’Agostino RS, Transaortic, video-assisted removal of a mobile left ventricular apical thrombus in a patient with aortic stenosis and severe left ventricular dysfunction: J Thorac Cardiovasc Surg, 2016; 151; e1-3

SARS-CoV-2/COVID-19

In Press

25 Nov 2022 : Case report  USA

A Case Report of Listeria Meningitis with Severe Rhabdomyolysis and Normal Renal Function

Am J Case Rep In Press; DOI: 10.12659/AJCR.938024  

24 Nov 2022 : Case report  Japan

Cardiac Arrest Following Torsades de Pointes Caused by Hypokalemia and Catecholamines in a Patient with Con...

Am J Case Rep In Press; DOI: 10.12659/AJCR.938609  

24 Nov 2022 : Case report  Denmark

A Large Pericardial Cyst in the Left Cardiophrenic Causing Persistent Chest Pain and Cough: A Case Report

Am J Case Rep In Press; DOI: 10.12659/AJCR.937785  

24 Nov 2022 : Case report  USA

Uterine Arteriovenous Malformation (AVM) – a Potentially Life-Threatening Cause of Post-Partum Vaginal Blee...

Am J Case Rep In Press; DOI: 10.12659/AJCR.938559  

Most Viewed Current Articles

13 Jul 2022 : Case report  USA

Whistling Scrotum: An Unusual Presentation of Pneumomediastinum in the Setting of an Open Scrotal Wound

DOI :10.12659/AJCR.936441

Am J Case Rep 2022; 23:e936441

23 Feb 2022 : Case report  USA

Penile Necrosis Associated with Local Intravenous Injection of Cocaine

DOI :10.12659/AJCR.935250

Am J Case Rep 2022; 23:e935250

06 Dec 2021 : Case report  Brazil

Lipedema Can Be Treated Non-Surgically: A Report of 5 Cases

DOI :10.12659/AJCR.934406

Am J Case Rep 2021; 22:e934406

17 Feb 2022 : Case report  Oman

Myocarditis, Pulmonary Hemorrhage, and Extensive Myositis with Rhabdomyolysis 12 Days After First Dose of P...

DOI :10.12659/AJCR.934399

Am J Case Rep 2022; 23:e934399

Your Privacy

We use cookies to ensure the functionality of our website, to personalize content and advertising, to provide social media features, and to analyze our traffic. If you allow us to do so, we also inform our social media, advertising and analysis partners about your use of our website, You can decise for yourself which categories you you want to deny or allow. Please note that based on your settings not all functionalities of the site are available. View our privacy policy.

American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923