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CARDIOVASCULAR ANESTHESIOLOGY

Left Ventricular Mass: Intraoperative Transesophageal Echocardiography for Evaluation and Management

From the Department of Anesthesiology, David Geffen School of Medicine at the University of California, Los Angeles, California.

Address correspondence and reprint requests to Jonathan K. Ho, MD, UCLA Anesthesiology, Box 957403, 757 Westwood Blvd., Suite 3302, Los Angeles, CA 90095-7403. Address e-mail to jkho{at}mednet.ucla.edu.

A 29-yr-old obese man with recent embolic stroke was brought to the operating room for resection of presumed intracardiac neoplasm suggested by preoperative imaging, including transthoracic echocardiography and cardiac magnetic resonance imaging. A significant history of cocaine use was revealed before surgery.

The intraoperative transesophageal echocardiography (TEE) examination revealed mildly decreased left ventricular (LV) function (ejection fraction 45%) and confirmed a 25 x 15 mm mobile, pedunculated mass in the LV attached near the apex. A combination of mid-esophageal and transgastric views were used to image the mass, which was homogenous, noncalcified and noncavitated with higher echogenicity relative to myocardial tissue (Figs. 1 and 2). Regional wall motion abnormalities that were not described on initial studies were observed in the apex near the point of attachment of the mass. The apical anterior region was dyskinetic at the site of attachment with hypokinesis of the apical septal, lateral, and inferior segments (Video loop 1; please see video clip available at www.anesthesia-analgesia.org).

View larger version (17K): [in this window] [in a new window]   Figure 1. In the mid-esophageal two-chamber view, the mass can be seen in the left ventricular apex. LA = left atrium; LV = left ventricle; Mass indicated by arrow.

View larger version (19K): [in this window] [in a new window]   Figure 2. The transgastric long axis view of the left ventricle (LV) demonstrates the mass (indicated by arrow).

Echocardiography (transthoracic and TEE) remains the imaging modality of choice in the initial assessment of cardiac sources of emboli. In formulating the differential diagnosis of an intracardiac mass, the examiner must evaluate the size, shape, mobility, location, and myocardial attachment or infiltration in addition to considering the overall clinical scenario. Although pathologic intracardiac masses can be due to infectious processes or malignancy, thrombus is a common intraventricular mass. LV thrombi are usually located in the apex in association with an infarcted region. LV tumors tend to be intramural rather than pedunculated, and may alter the echogenic properties and regional contractile function of the tissue.

Although LV thrombus was historically a frequent complication of MI, occurring in 20%–60% of patients, the incidence has substantially decreased to approximately 4.3% since the advent of thrombolytic therapy and percutaneous interventions.1 Most thrombi develop within the first 14 days after an MI and can lead to systemic embolization in about 10% of the patients.1 LV thrombus is typically managed conservatively with anticoagulation, whereas surgical thrombectomy is reserved for patients at high risk for embolization due to prior embolic events, mobile and/or protrusive thrombus, or failed anticoagulation therapy.2,3 In a patient presenting for emergent coronary artery bypass grafting, detection of a previously unknown LV thrombus will greatly impact the intraoperative management. Resection of the thrombus may be considered, and the echocardiographer must monitor the thrombus during the procedure, particularly at times of cardiac manipulation and before release of aortic cross-clamp. Manipulation or instrumentation of the LV, including placement of a LV vent, should be limited and avoided when possible.

During a planned surgical resection of an intracardiac mass, intraoperative TEE is used to confirm the presence of the reported mass in the expected location and to excluded additional cardiac masses or disease processes. TEE can also guide instrumentation of the heart if the lesion is located near the cannulation sites. After the procedure, TEE can confirm complete resection of the mass. A change in surgical plan as a result of new information provided by intraoperative TEE was reported in 16% of the patients undergoing resection of intracardiac masses in one study.4

In our patient, the intraoperative TEE examination established the correct diagnosis and altered management of the case. Medical management was considered as an alternative to surgery, although LV thrombectomy was ultimately performed. This case strongly demonstrates the need for a thorough perioperative TEE examination in patients presenting with intracardiac masses.

Footnotes

This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Accepted for publication May 7, 2008.

Supported by Intramural Departmental Funds.

REFERENCES

1. Rehan A, Kanwar M, Rosman H, Ahmed S, Ali A, Gardin J, Cohen G. Incidence of post myocardial infarction left ventricular thrombus formation in the era of primary percutaneous intervention and glycoprotein IIb/IIIa inhibitors. A prospective observational study. Cardiovasc Ultrasound 2006;4:20[Medline]
2. Early GL, Ballenger M, Hannah H III, Roberts SR. Simplified method of left ventricular thrombectomy. Ann Thorac Surg 2001;72:953–4[Abstract/Free Full Text]
3. Fortier S, Demaria RG, Pelletier GB, Carrier M, Perrault LP. Left ventricular thrombectomy in a cocaine user with normal coronary arteries. J Thorac Cardiovasc Surg 2003;125:204–5[Free Full Text]
4. Dujardin KS, Click RL, Oh JK. The role of intraoperative transesophageal echocardiography in patients undergoing cardiac mass removal. J Am Soc Echocardiogr 2000;13:1080–3[Web of Science][Medline]

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This Article Full Text (PDF) CME: Take the course for this article: Echo Rounds Echo Loop Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Ho, J. K. Articles by Marijic, J. Search for Related Content PubMed PubMed Citation Articles by Ho, J. K. Articles by Marijic, J. Related Collections Cardiovascular Heart Monitoring (Cardiac) Echo Rounds Video Clip