Young patient with left ventricular thrombus tumor

A 32-year-old male, was referred for Cardiac Surgery from another hospital.

He presented to another hospital with history of acute onset of severe headache, nausea and vomiting, associated with extensive heat exposure. There was no history of chest pain or any other cardiac symptoms. ECG was reported as normal. Chest X-ray showed mild to moderate left pleural effusion. He was taken up for CT scan of brain which confirmed acute infarct left posterior parietal territory. He never had any focal neurological deficit. His transthoracic echocardiogram showed a firm mass attached to the lateral wall of left ventricle (LV) with no regional wall motion abnormality but high cardiac markers.

He was referred for emergency cardiac surgery. Before transferring this patient, we requested to do a coronary angiogram. But due to CT brain findings CT coronary angiogram was done in that hospital and reported as normal. In view of the CT scan finding and echocardiogram, it was decided to remove the LV mass, with provisional diagnosis of LV thrombus/tumor causing embolization to brain, on emergency basis.

Surgical Procedure

Intra Operative transesophageal echocardiogram showed normal LV function with no Regional Wall Motion Abnormalities. Transmitral complete resection of the LV mass was done under cardio pulmonary bypass. Thoracoscopic inspection of the left ventricle done through the mitral orifice to make sure that complete resection of the mass was done. Transaortic inspection was also done to exclude any residual debris. Patient made an uneventful post-op recovery.

Routine post-op echocardiogram done on post-operative day 3, showed moderate LV dysfunction (RWMA corresponding with the resected mass territory). Meanwhile, histopathology report of the mass was reported as thrombus. Transradial, coronary angiogram was done which showed re-canalized left circumflex with residual stenosis. He was subjected for stenting on left circumflex artery and had a smooth outcome. He was discharged on 10th post-operative day. Follow up 2D Echo at OPD revealed normal LV function with no RWMA.

Discussion

Young patient with no history of cardiac symptoms presented with CVA and on echocardiogram showed thrombus in LV. It was not easy to exclude a tumor mass in the echocardiogram. In view of acute CVA on CT scan and further to avoid more neurological problems, it was decided to remove the mass/thrombus. Transmitral approach was used aided by thoracoscope for complete clearance. Left ventriculotomy was avoided.

Conclusion

Young patient, with LV thrombus and history of CVA, should be subjected to LV mass thrombus removal and short term anticoagulation to get a good recovery.

Left ventricular mass - Burjeel