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LETTER TO THE EDITOR
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 50-51

A case of left ventricular apical thrombus extending into left ventricular outflow tract and role of intraoperative transesophageal echocardiography


Department of Cardiac Anaesthesia, U N Mehta Institute of Cardiology and Research Centre Civil Hospital Campus, Ahmedabad, Gujarat, India

Date of Submission20-Jan-2022
Date of Decision29-Mar-2022
Date of Acceptance29-Mar-2022
Date of Web Publication20-May-2022

Correspondence Address:
Dr. Guriqbal Singh
Department of Cardiac Anaesthesia, U N Mehta Institute of Cardiology and Research Centre Civil Hospital Campus, Asarwa, Ahmedabad - 380 016, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jica.jica_5_22

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How to cite this article:
Singh G, Patel R. A case of left ventricular apical thrombus extending into left ventricular outflow tract and role of intraoperative transesophageal echocardiography. J Ind Coll Anesth 2022;1:50-1

How to cite this URL:
Singh G, Patel R. A case of left ventricular apical thrombus extending into left ventricular outflow tract and role of intraoperative transesophageal echocardiography. J Ind Coll Anesth [serial online] 2022 [cited 2022 Jul 1];1:50-1. Available from: https://www.jicajournal.in//text.asp?2022/1/1/50/345602

Sir,

The most common cause of left ventricular (LV) mass is thrombus and is typically seen in the presence of global LV systolic dysfunction, aneurysm, dilated cardiomyopathy, and areas of significant regional wall motion abnormalities, particularly in the apical region.[1] The greatest concern for LV thrombus is the potential for thromboembolism, resulting in stroke, myocardial infarction, mesenteric ischemia, renal infarction, gangrene of limbs, mortality, and is an indication for surgical removal.[2] Left ventricular outflow tract (LVOT) obstruction is another complication of LV thrombus but is rarely seen. Intraoperative transesophageal echocardiography (TOE) is an invaluable tool in the evaluation of intracardiac mass, can reliably identify the mass location, attachment, shape, size, and mobility while defining the extent of any consequent hemodynamic derangement, and is category II indication in intracardiac thrombectomy.[3]

A 34-year-old male patient presented with two episodes of syncope and had a history of anterior wall myocardial infarction (AWMI), managed by thrombolysis 3 years back. Preoperative examination revealed normal vital parameters and neurology. Coronary angiogram of the patient revealed normal epicardial coronaries. A computed tomography scan of the brain was done in view of the history of syncope, which showed right temporoparietal and right occipital infarct. Transthoracic echocardiography revealed an ejection fraction of 30% with severe apical and anterior wall hypokinesia and mobile echogenic structure measuring 70 mm × 31 mm, attached to LV apex, protruding into LVOT and causing an obstruction. The patient was immediately started on intravenous heparin infusion. In view of the large mobile apical LV clot, thrombectomy was planned. Heparin infusion was stopped 4 h preoperatively. On the day of surgery, after attaching a multiparameter monitor to the patient, right radial arterial and right internal jugular venous lines were secured under local anesthesia, and inotropes were attached to the central venous line due to anticipated hemodynamic instability because of severe LV dysfunction. Induction of anesthesia was done with injection etomidate 0.2 mg/kg, injection fentanyl 5 μg/kg, and injection vecuronium 0.1 mg/kg, followed by endotracheal intubation. Induction agents were administered in small doses for 60–90 s. Omniplane TOE probe (GE Vingmed 6Tc-RS) was inserted. Mid-esophageal (ME) five-chamber view showed a large, mobile, homogeneous mass with echogenicity similar to the myocardium, attached to LV apex and extending into LVOT hitting the aortic valve during systole. On the ME long-axis view, the measured size of the clot was 54 mm × 35 mm [Figure 1]. After midline sternotomy and pericardial opening, injection heparin 400 IU/kg was given, and cardiopulmonary bypass (CPB) was instituted. LV vent was not inserted in this case because of the risk of apical trauma. LV clot was removed by transaortic approach. After clot removal, the patient was weaned from CPB with the inotropic infusion of injection dobutamine 5 μg/kg/min and injection epinephrine 0.05 μg/kg/min and was stable hemodynamically. Re-evaluation of the heart with TOE showed no residual thrombus [Figure 2]. The patient was extubated after 5 h of mechanical ventilation and was discharged on the 8th postoperative day on oral anticoagulants and antiplatelet therapy.
Figure 1: (a) Mid-esophageal five-chamber view showing left ventricular thrombus extending into left ventricular outflow tract. (b) Mid-esophageal long-axis view showing left ventricular thrombus of size 54 mm × 35 mm. (c) Mid-esophageal two-chamber view. (d) Mid-esophageal long-axis view showing left ventricular thrombus hitting the aortic valve

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Figure 2: (a) Mid-esophageal long-axis view showing left ventricular thrombus going into left ventricular outflow tract during systole. (b) Re-evaluation of heart following thrombectomy showing no residual thrombus. (c) Removed left ventricular clot

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TOE examination of LV thrombus should include multiple views through a complete cardiac cycle. ME four-chamber, two-chamber, and deep transgastric views generally provide the best assessment of LV apex. The anesthesiologist must image the thrombus continuously during procedures, particularly at the time of cardiac manipulation, before the release of aortic cross-clamp or instrumentation of LV, because manipulation of the ventricle may dislodge or fracture the thrombus. Evaluation of complete excision of LV apical thrombus can only be done by the TOE if it is done by transaortic approach as in this case and not by ventriculostomy. Echocardiographic features that differentiate LV thrombus from other intraventricular mass include location in abnormally functioning myocardium, movement concordant with underlying tissue, and well-delineated borders distinct from underlying myocardium. In this patient, a history of old AWMI and similar features favors the diagnosis of LV thrombus. TOE is a procedure of choice for differentiating LV thrombus from other possible LV masses such as tumors, myxoma, and fibromas. LV myxoma appears homogeneous with hyperlucent central area and fibromas are intramural with central calcification. TOE plays important role in delineating and demarcating the cardiac masses and in checking their adequacy of excision.[4] Events of embolism can occur even after the resolution of LV thrombus, suggesting the need to continue anticoagulant therapy for a longer duration of time.[5]

High pressure of LV during systole could increase the risk of systemic embolization, while systolic prolapse of mass via aortic valve could result in severe LVOT obstruction and sudden death. Hence, the maintenance of adequate preload and afterload and avoiding tachycardia and hypertension perioperatively were important concerns in this patient to avoid LVOT obstruction and the risk of embolization.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was financially supported by the U. N. Mehta Institute of Cardiology and Research Centre.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jadbabaie F. Cardiac masses and embolic sources. In: Perrino AC, editor. A Practical Approach to Transesophageal Echocardiography. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2015. p. 424-34.  Back to cited text no. 1
    
2.
Dinesh Kumar US, Shetty SP, Sujay KR, Wali M. Left ventricular mass: A tumor or a thrombus diagnostic dilemma. Ann Card Anaesth 2016;19:728-32.  Back to cited text no. 2
    
3.
Taneja R, Aguirre MA, Shi C, Greilich PE. Embolization of left ventricular apical thrombus during cardiac surgery. Anesth Analg 2010;111:74-5.  Back to cited text no. 3
    
4.
Karuppiah S, Dharmalingam S, Sahajanandan R, George G. Role of transoesophageal echocardiography in peri-operative management of cardiac hydatid cyst. Indian J Anaesth 2015;59:753-4.  Back to cited text no. 4
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5.
Cruz Rodriguez JB, Okajima K, Greenberg BH. Management of left ventricular thrombus: A narrative review. Ann Transl Med 2021;9:520.  Back to cited text no. 5
    


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