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J Thorac Cardiovasc Surg 2003;125:204-205
© 2003 The American Association for Thoracic Surgery
Brief Communications |
From the Departments of Surgerya and Cardiology,b Montreal Heart Institute, Montreal, Quebec, Canada, and the Cardiovascular Surgery Unit,c Arnaud de Villeneuve Teaching Hospital, Montpellier, France.
Received for publication April 18, 2002. Accepted for publication May 1, 2002. Address for reprints: L. P. Perrault, MD, PhD, Research Center, Montreal Heart Institute, 5000 Belanger St E, Montreal, Quebec, Canada H1T 1C8 (E-mail: lpperrau{at}icm.umontreal.ca).
Formation of a left ventricular (LV) thrombus may follow an anterior acute myocardial infarction (AMI) and is associated with a significant risk of systemic embolization.
1 A 37-year-old man was seen at a referring hospital with acute ischemia of the right lower limb with pain, paresthesia, and paresis. There was a history of cocaine use by inhalation, with description of anginal pain during bouts of drug use and a more sustained episode of thoracic pain about 4 months before admission. There were no signs or symptoms of congestive heart failure. A successful right femoral thrombectomy was performed with general anesthesia, and intravenous heparin therapy was instituted. The electrocardiogram on admission revealed an anteroseptal myocardial infarction of undetermined date. A transthoracic echocardiogram was performed to identify the source of embolism and revealed a severe LV dysfunction with an ejection fraction of 30%. The transesophageal echocardiogram showed an apical mural thrombus with a large, pedunculated, mobile, heterogeneous mass floating in the LV (Figure 1). A coronary angiogram was done before the operation and showed no significant coronary artery stenosis.
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The first report of an association between cocaine use and AMI was in 1982. 2 The risk is increased 24 times in the first 60 minutes after cocaine use, and this is unrelated to the amount ingested. 2 The exact incidence of AMI among cocaine users is unknown, but about 6% of patients who arrive at the emergency department with cocaine-induced retrosternal pain have enzymatic evidence of AMI. 2 The formation of a ventricular thrombus after AMI is common no matter the cause, despite therapeutic anticoagulation. 1 Also, ventricular thrombi usually appear after anterior AMI and early in its course, with considerable chances of systemic embolization depending on the morphologic appearance. 3
Few reports have been published about LV thrombus associated with cocaine-induced AMI, 4,5 but intracavitary cardiac evaluation is required even when no sign of embolization is present, because cocaine is associated with platelet activation, formation of platelets, and thrombosis promotion. 6 Postinfarction LV thrombi are at risk of embolization, especially if they are mobile and pedunculated, 3 as was demonstrated in our case with a clear episode of right lower limb ischemia. A role for systemic anticoagulation and thrombolysis has already been demonstrated, but this may sometimes lead to the formation of an unstable thrombus, emphasizing the need of a close echocardiographic and surgical follow-up. 7
The indications for surgical thrombectomy are an episode of systemic or coronary embolization or a change in the morphologic features. 7,8 Different surgical techniques have been described, such as left ventriculotomy, 8 transaortic video-assisted, 9 and left atrial 3 approaches. Video-assisted techniques can be useful to facilitate exposure of the inner LV and confirm complete excision of the thrombus. Importantly, techniques that avoid ventriculotomy allow preservation of the LV function and a better postoperative course.
With a history of systemic embolization in a patient who uses cocaine, transesophageal echocardiographic evaluation is mandatory to excluded LV thrombus. Although anticoagulation is required, surgical thrombectomy is the sole treatment that will avoid recurrence. Video-assisted techniques are especially helpful in the presence of ventricular dysfunction when ventriculotomy would compromise LV function, as was the case here with a reduced LV ejection fraction related to previous AMI.
References
This article has been cited by other articles:
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  J. K. Ho, N. Dhamija, A. Yezbick, A. Mahajan, and J. Marijic Left Ventricular Mass: Intraoperative Transesophageal Echocardiography for Evaluation and Management Anesth. Analg., October 1, 2008; 107(4): 1153 - 1154. [Full Text] [PDF]
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