Complicated Massive Left Ventricular Thrombus and Surgical Treatment

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.

Figure 1.

Echocardiographic assessment of LV thrombus localization: Illustration of a 4.5×4.2 cm thrombus localized in the apex of the left ventricle.

Figure 2.

Thrombus adherence to LV wall: Apical 4-chamber view of the left ventricular thrombus with deep septal and trabecular position.

Figure 3.

Coronary angiography of the circumflex artery: Illustration of a 60% circumflex stenosis highlighted by arrow.

Figure 4.

Coronary angiography of the right coronary artery: Illustration of a 80% stenosis of the small right posterior branch highlighted by arrow.