Clinical Profile:
A 34 years old male presented to our hospital with two episodes of
syncope. On evaluation he was found to have acute embolic infarcts in
multiple areas of his brain (Figure – 1 A - C). His neurological
examination was normal and he gave a history of anterior wall myocardial
infarction three years ago which was thrombolysed. Echocardiography
showed severe Left Ventricular (LV) dysfunction with an ejection
fraction of 30% and a dilated LV cavity. There was a massive freely
mobile clot in the LV attached to the apex, protruding into the left
ventricular outflow tract (LVOT) and hitting the aortic valve with every
systole (Figure – 2 A & supplementary video). There was no evidence of
LV aneurysm and the clot occupied a major part of the LV cavity.
Computed tomography confirmed the echocardiographic findings (Figure –
2 B). On coronary angiography, the left anterior descending artery was
completely recanalized and other vessels were minimally diseased. As the
clot was huge and freely mobile with high risk of further embolic
showers, we planned LV thrombectomy in spite of his acute stroke.
Cardio-plumonary-bypass was established with aorto-bi-caval cannulation.
After achieving cardioplegic arrest of the heart, aorta was opened.
With, minimal retraction of the aortic valve leaflets, the clot was
found in its entirety within the cavity. The apical attachment of the
thrombus was disconnected and the clot was removed completely (Figure –
2 C, D). Apical endocardium was found free of scars and the LV cavity
was washed thoroughly with saline to flush any residues. He recovered
uneventfully and his post-operative echocardiography confirmed an LV
cavity free of any clots (Figure – 3A). His pre-discharge CT brain
showed reduction in size of the infarcts and ruled out haemorrhagic
transformation (Figure – 3B - D). His haematological work-up was normal
and the surgical specimen was found to contain elements of old clot on
histopathology. He is neurologically normal and is on regular follow up.