Myocardial Ischemia And A Friable Left Ventricular Mass: A Simplified Cardioscopic Approach
Joseph M. Arcidi1, Muhammad T. Shakoor2, Wendy J. Sharp2, Rubina A. Mirza3, Hanumanth K. Reddy3.
1Michigan Center for Heart Valve Surgery, Flint, MI, USA, 2Poplar Bluff Regional Medical Center, Poplar Bluff, MO, USA, 3Cardiovascular Institute of Southern Missouri, Poplar Bluff, MO, USA.
OBJECTIVE: Transaortic resection utilizing video-assisted cardioscopy has been described for left ventricular masses including myxomas and formed mural thrombi, however the feasibility of this approach with large, friable thrombi is less recognized. We recently managed a patient with a sizeable left ventricular thrombus using transaortic cardioscopy who presented with probable coronary embolization.
METHODS: This 45yo woman had been symptom-free after a small myocardial infarction 6 years earlier until presenting with angina, deep precordial T-wave inversions, absent R-wave progression, and a troponin of 4.01. Echocardiography showed a solitary, mobile 4.2cm left ventricular mass attached anteroapically without a stalk and a 40% ejection fraction with global hypokinesis. Coronary angiography demonstrated left-dominance and trivial coronary disease. The patient became catecholamine-dependent preoperatively. At operation, a complete transverse aortotomy was performed with handheld retraction of the right and noncoronary leaflets. A 5mm-30° rigid video telescope was exclusively used to visualize the mass, aided by dual left atrial vent catheters, one positioned under direct vision through a small left atrial dome incision. The mass had a shaggy appearance consistent with thrombus, and disintegrated when touched revealing a central cavity; therefore, it was necessary to debride the bulky, immediately visible portion piecemeal, using thin shafted thoracoscopic instruments, to expose the broad apical attachment. The thrombus was interwoven over a 3x3cm area with apical trabeculae, which were also resected. Postbypass echocardiography showed excellent aortic valve competence.
RESULTS: The patient, whose history included migraines, awoke without neurologic deficits and was discharged without complications on postoperative day 7 on oral anticoagulation. The pathology, in addition to organizing thrombus, demonstrated enlarged myocyte nuclei and a lymphocytic infiltrate consistent with chronic myocarditis, and the patient was referred for specialized treatment.
CONCLUSIONS: Among sparse published reports, this unique case may represent the largest thrombus removed transaortically with video-assisted cardioscopy, with pathology that creates more surgical risk than formed mural thrombi. Complete aortic transection combined with a conventional 5mm-30° rigid telescope provided excellent visualization for safe and complete resection.
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