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Surgical removal of a large mobile left ventricular thrombus via left atriotomy Daizo Tanaka, MD; Shinya Unai, MD; James T. Diehl, MD; Hitoshi Hirose,

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Presentation on theme: "Surgical removal of a large mobile left ventricular thrombus via left atriotomy Daizo Tanaka, MD; Shinya Unai, MD; James T. Diehl, MD; Hitoshi Hirose,"— Presentation transcript:

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

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?)

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)

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

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

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)


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