Cardioscope-Assisted LV Clot Evacuation

Case Summary: A 48-year-old diabetic man presented with sudden onset paraplegia and pain in the lower extremities lasting four hours. Lower limb pulses were absent and CT angiogram revealed a saddle embolus at the aortoiliac bifurcation. Urgent bilateral retrograde femoral embolectomy was attempted, but failed. The patient underwent urgent laparotomy, aortotomy, and clot evacuation with an uneventful recovery. On evaluation, a large left ventricle (LV) mass protruding into the left ventricular outflow tract (LVOT) was noted on transesophageal echocardiography (TEE). A large LV thrombus was confirmed by cMRI.

A midline sternotomy approach was performed. Total cardiopulmonary bypass with aorto-bicaval cannulation, pulmonary artery (PA) venting, and Del Nido cardioplegic arrest were started. An oblique aortotomy was performed and part of the clot protruding into LVOT was excised through the aortotomy. A 5 mm, 300 endoscope was inserted through the aortotomy into the LV cavity. A clot extending from the lateral wall onto the underside of AML, PML onto the base of papillary muscles and further up to the apex, was visualised. The radial artery (RA) was opened and the LV was approached trans-septally via the mitral valve. Part of the thrombus was excised through this approach. Further cardioscopy revealed residual thrombus at the base of the papillary muscle nearing the apex. As this area was inaccessible, an LV apical fish-mouth incision was made. The residual thrombus was excised successfully via the apical route. Cardioscopy through the LV apex confirmed the completeness of the thrombectomy. The heart recovered in sinus rhythm and post-CPB TEE revealed no residual LV thrombus, with trivial MR and AR, and good LV contractility. The patient made an uneventful recovery, and was discharged on the 9th post-operative day.

Histopathology of the excised mass reported it to be chronic thrombus. TTE after one month revealed no residual or recurrent LV mass. The work-up for spontaneous thrombosis included APLA antibody syndrome, Protein C and S deficiencies, Factor V Leiden mutation, and hyper homocystinemia, which were all negative. The patient is currently on oral anticoagulation.

Conclusions: Inaccessible LV masses can be successfully tackled by a cardioscope-assisted approach with the addition of an LV apical incision when deemed necessary. The magnification and precision offered by the cardioscope ensures the completeness of the resection and the prevention of inadvertent injury.