Interact CardioVasc Thorac Surg 2009;8:596-598. doi:10.1510/icvts.2008.201517
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Cardiac general |
Migration of left ventricular thrombus causing abdominal aortic embolism during cardiac surgery in a child with severe left ventricular dysfunction
Mitsugi Nagashimaa,*,
Shinji Takanob,
Eiichi Yamamotoc and
Takashi Higakic
a Department of Surgery, Ehime University School of Medicine, Stroke and Cardiovascular Center, 791-0295 Shitsukawa, Toon City, Ehime Prefecture, Japan
b Department of Cardiovascular Surgery, Ehime Prefectural Niihama Hospital, Japan
c Department of Pediatrics, Ehime University of Medicine, Japan
Received 30 December 2008;
received in revised form 31 January 2009;
accepted 3 February 2009
*Corresponding author. Tel.: +81-89-955-9835; fax: +81-89-960-5335.
E-mail address: mitsugi{at}aqua.plala.or.jp, mitsugi{at}m.ehime-u.ac.jp (M. Nagashima).
 |
Abstract
|
|---|
A 1-year-old girl with severe left ventricular dysfunction presented with large floating thrombi in the left ventricle. Surgical thrombectomy was urgently required. During cannulation, transesophageal echocardiogram detected that the thrombus had vanished from the left ventricle. Whole body angiogram under very low-flow cardiopulmonary bypass successfully obtained the exact site of embolization with reducing total amount of contrast media in the operating room. Consequently, under deep hypothermic circulatory arrest, the obstructive thrombi at the abdominal aorta were successfully removed using Fogarty catheters from ascending aortotomy. Although delayed sternal closure was postoperatively required, no complication including thromboembolic events were observed for a 1.5-year follow-up period.
Key Words: Thrombosis; Cardiomyopathy; Intraoperative angiography
|
1. Introduction
|
|---|
Left ventricular thrombus is a common complication of dilated cardiomyopathy even in early childhood [1, 2]. We present a successfully, surgically treated case with intraoperative migration of the left ventricular thrombus which led to embolization at the abdominal aorta.
|
2. Case report
|
|---|
At 13 months old, a girl suffered from appetite loss and deterioration in physical activity although she grew and developed normally. Echocardiogram showed a severely enlarged left ventricle (LV) with an impaired ejection fraction (EF) of 0.15. She was treated as heart failure due to dilated cardiomyopathy. Ten days after admission, echo-cardiogram demonstrated two connected large thrombi almost floating in LV (Fig. 1). She was transferred to us for an emergency operation. The patient underwent cardiac surgery using cardiopulmonary bypass (CPB). After systemic heparinization, transesophageal echocardiogram detected that the thrombus had vanished from the LV and the femoral arterial pressure suddenly decreased. These findings strongly suggested that thromboembolism occurred around the abdominal aorta, although other large systemic vessels should be examined to confirm whether they were occluded or not. Whole body angiogram including three neck vessels, abdominal arteries and arteries of the lower extremity should be required. To reduce total amount of contrast media and to display effectively using a small amount of media, hypothermic low-flow bypass was considered. Rectal temperature did not decrease so rapidly that another blood perfusion was supplied through the femoral artery. At pharyngeal temperature of 20 °C and rectal temperature of 23 °C, very low-flow bypass started. Then contrast media injection through the port of the arterial cannula demonstrated no obstruction at the three neck vessels. Then, a second injection revealed the total obstruction of abdominal aorta just below the celiac trunk branching (Fig. 2a). Under deep hypothermic circulatory arrest, thrombectomy was performed using Fogarty catheters through the ascending aortotomy (Fig. 2b). At the same time, the three neck vessels were closed using tourniquets for preventing cerebral embolism. Thrombi were obtained including a main snowman-like thrombus. Then, contrast media injection showed no obstruction at the abdominal aorta and the lower extremity arteries (Fig. 2c). Reperfusion was retrogradely started through the femoral artery to evacuate air and the remaining thrombus. Another small thrombus came out through the incision on the ascending aorta. An exploration through the aortic valve and the mitral valve confirmed no other thrombus in the heart. Circulatory arrest time was 19 min and aortic cross-clamp time was 52 min. As chest closure elevated left atrial pressure to 16 mmHg because of LV dilatation, primary chest closure was abandoned. The chest was closed on the fifth postoperative day without any serious unstable hemodynamics. Then she was treated with medication of warfarin and β-blocker up to the present time. A recent echocardiogram demonstrated left ventricular EF of 25% and only mitral regurgitation because of these medications. She was doing well 1.5 years after the operation without any thromboembolic or hemorrhagic events.
View larger version (38K):
[in this window]
[in a new window]
|
Fig. 1. Echocardiogram of left ventricular long axis view showing two connected floating large thrombi and its illustration (right). LV: left ventricle, Ao: aorta, LA: left atrium.
|
|
View larger version (116K):
[in this window]
[in a new window]
|
Fig. 2. (a) Angiogram of abdominal aorta under very low-flow bypass showing total occlusion just below the celiac trunk branching. (b) Thrombectomy using a Fogarty catheter. (c) Angiogram of abdominal aorta under deep hypothermic circulatory arrest after removal of thrombi.
|
|
|
3. Comments
|
|---|
Left ventricular thrombus is a major consequence of dilated cardiomyopathy and sometimes causes lethal systemic thromboembolization [1, 2]. Systemic thromboembolism in adult patients with chronic heart failure due to severe LV dysfunction occurred in incidence rates of 2–5% of patients per year [3, 4]. Although there was no large volume study about the incidence of LV thrombus in children with dilated cardiomyopathy, several reports showed around 8–30%. Günthard and colleagues [1] detected LV thrombi in 10 of 130 children with dilated cardiomyopathy by echocardiogram or autopsy. John and colleagues reported two systemic embolizations out of 15 occurrences of intracardiac thrombus in 11 children with cardiomyopathy during seven years of observation [5].
Treatment of LV thrombi has not been established yet especially in children. Several drugs including warfarin, acetylsalicylic acid, dipyridamole, and heparin were utilized for children [1, 2, 5]. Although many of them successfully dissolved the thrombus, serious systemic embolization sometimes occurred [1, 2]. Visser and colleagues [6] reported that a protruding configuration of the thrombus significantly induced systemic embolization. Because LV thrombus was almost floating in our case, surgical thrombectomy was initially considered. The exact site of embolization should be urgently detected in the operating room. Angiogram was the most accurate and effective unless computed tomography was available in the operating room. It was also required to reduce the amount of contrast media for protecting the postoperative fragile renal function under LV failure. Then, we applied very low-flow bypass under deep hypothermia, where contrast media would not move rapidly in the vessels. By this technique it was possible to make an effective image simultaneously with reducing amount of contrast media.
Little information was reported about the methods preventing distal embolization of cardiac thrombus during heart surgery. Gentle manipulation during cannulation and avoiding arrhythmia should be necessary. Intra-aortic filtration device was effective to remove atheromatous tissue or debris in adult patients with coronary bypass surgery [7]. However, this device was designed for only adult patients. As it was considered that the initiation of heparin administration might be the cause of mobilization of the thrombus, thromboembolism could be inevitable in our case.
Surgical approach for abdominal aortic thrombus was performed through thoracotomy, abdominal incision or retroperitoneal approach [8]. In our case, as sternotomy and full systemic heparinization were already done, another large surgical incision may complicate hemostasis and bring damage for the infant body. Then, we decided on thrombectomy using Fogarty catheters through ascending aortotomy without abdominal approach. Retrograde perfusion via the femoral arterial cannula after the removal of the thrombus was important to evacuate air and some remaining thrombi. At the same time, three neck vessels should not be perfused for preventing cerebral embolism. Takagi and colleagues [9] used this technique for thoraco-abdominal aortic thrombus in an adult patient and obtained a good result.
In conclusion, in a child with severe left ventricular dysfunction, intraoperative embolization of left ventricular thrombus to abdominal aorta was effectively detected using a small amount of contrast media under hypothermic low-flow cardiopulmonary bypass. Fortunately, thrombi were successfully removed by Fogarty catheters through ascending aortotomy under deep hypothermic circulatory arrest. In this emergent condition, this technique was simple and very useful for this small child although this procedure may not be reproducible.
|
References
|
|---|
- Günthard J, Stocker F, Bolz D, Jäggi E, Ghisla R, Oberhänsli I, Wyler F. Dilated cardiomyopathy and thrombo-embolism. Eur J Pediatr 1997;156:3–6.[CrossRef][Medline]
- Chang YC, Wu JM, Wu MH, Wang JK, Lue HC. Left ventricular thrombi in children with dilated cardiomyopathy. J Formos Med Assoc 1995;94:469–473.[Medline]
- Cioffi G, Pozzoli M, Forni G, Franchini M, Opasich C, Cobelli F, Tavazzi L. Systemic thromboembolism in chronic heart failure. A prospective study in 406 patients. Eur Heart J 1996;17:1381–1389.[Abstract/Free Full Text]
- Cokkinos DV, Haralabopoulos GC, Kostis JB, Toutouzas PK, HELAS investigators. Efficacy of antithrombotic therapy in chronic heart failure: the HELAS study. Eur J Heart Fail 2006;8:428–432.[Abstract/Free Full Text]
- John JB, Cron SG, Kung GC, Mott AR. Intracardiac thrombi in pediatric patients: presentation profiles and clinical outcomes. Pediatr Cardiol 2007;28:213–220.[CrossRef][Medline]
- Visser CA, Kan G, Meltzer RS, Dunning AJ, Roelandt J. Embolic potential of left ventricular thrombus after myocardial infarction: a two-dimensional echocardiographic study of 119 patients. J Am Coll Cardiol 1985;5:1276–1280.[Abstract]
- Wimmer-Greinecker G. International Council of Emboli Management (ICEM) study group. Reduction of neurologic complications by intra-aortic filtration in patients undergoing combined intracardiac and CABG procedures. Eur J Cardiothorac Surg 2003;23:159–164.[Abstract/Free Full Text]
- Lofland GK, Russo P, Sethia B, de Leval M. Aortic thrombosis in neonates and infants. Ann Surg 1988;208:743–745.[Medline]
- Takagi H, Mori Y, Umeda Y, Fukumoto Y, Matsuno Y, Mizuno Y, Hirose H. Surgical treatment of thoracoabdominal aortic mural and floating thrombi extending to infrarenal aorta. J Vasc Surg 2003;37:1324–1327.[CrossRef][Medline]
|
|
Top
Abstract
1. Introduction