Slide 1

Surgical removal of a large mobile left ventricular thrombus via left atriotomy Daizo Tanaka, MD; Shinya Unai, MD; James T. Diehl, MD; Hitoshi Hirose, MD Division of Cardiothoracic Surgery Department of Surgery Thomas Jefferson University Hospital Slide 2 Introduction Left ventricular (LV) thrombus = Life-threatening complication of severe LV dysfunction Possible treatment options Anticoagulation Thrombolysis Surgical thrombectomy Especially for a large mobile thrombus Conventional ventriculotomy would make LV function even worse. Alternative approach (Atriotomy or Aortotomy?) Slide 3 Case report 37-year-old female PMH: Postpartum cardiomyopathy, multiple PE HPI: Worsening dyspnea on exertion and fatigue for a week RHC: CI 1.5 l/min/m 2 TTE: EF 10% (20% originally) Large apical pendunculated LV thrombus (3 x 3 cm) Slide 4 Operation Approach: Right-sided left atriotomy The LV thrombus located at the apex and was hanging by a small stem at the base of the papillary muscle extracted with gentle traction Cross clamp: 20 min. no issue weaning from CPB Postoperative course Placed on anticoagulation and discharged on POD10 without any embolization event or inotropic support. TTE: only minimally remaining thrombus (3x4mm) Pathology: a thrombus w/o malignant component Slide 5 Discussion Surgical LV thrombectomy possible approaches Conventinal Ventriculotomy Most reliable for complete removal Possibly cause further deterioration of LV function Atriotomy and Aortotomy Limited view and maneuver Atriotomy would be better than aortotomy Preserve LV function Slide 6 Atriotomy as the standard approach for emergency LV thrombectomy Most cases of LV thrombus = Poor LV function Possible future LVAD Favors atriotomy over ventriculotomy Most cases of emergency thrombectomy = Mobile pendunculated thrombus Extraction is possible even with limited view (A standby of thoracoscope is recommended)