Giant left ventricular thrombus embolism into the abdominal aorta

Urmeneta Ulloa, J.; Pérez Guerrero, A.; Molina Borao, I.; Fuentes Gorgas, F.; Miñano Oyarzabal, A.

doi:10.1016/j.redare.2018.06.004

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Urmeneta Ulloa, A. Pérez Guerrero, I. Molina Borao, F. Fuentes Gorgas, A. Miñano Oyarzabal" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Urmeneta Ulloa" "email" => array:1 [ 0 => "javierurmeneta@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pérez Guerrero" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Molina Borao" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Fuentes Gorgas" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Miñano Oyarzabal" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Universitario Miguel Servet, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Embolismo de trombo ventricular izquierdo gigante hacia aorta abdominal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2059 "Ancho" => 1583 "Tamanyo" => 147089 ] ] "descripcion" => array:1 [ "en" => "Modified two chamber apical TEE: (A) left ventricular thrombus (LVT) and (B) SonoVue® contrast showing the giant, pedunculated apical LVT." ] ] ] "textoCompleto" => "A 65-year-old woman, ex-smoker, diabetic and dyslipidaemic, with a history of acute anteroseptal myocardial infarction (AMI) in 2007 that was treated with fibrinolysis and subsequent urgent coronary angiography, during which percutaneous coronary intervention (PCI) was performed on the mid segment of the anterior descending artery (DA) and on the mid to proximal segment of the right coronary artery (RA), was admitted in May 2017 for a stroke. Transthoracic echocardiography (TTE) showed a suboptimal transthoracic window, so SonoVue® contrast medium was administered. The resulting image showed: dilated left ventricle (LV), mild-moderate LV systolic dysfunction (40% left ventricular ejection fraction [LVEF] estimated by the Simpson method), extensive apical akinesia with aneurysmal formation, and a pedunculated, mobile, echodense image measuring 38mm×35mm in the same region that was not captured by the SonoVue® contrast, compatible with apical thrombus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>In view of this finding, the patient was transferred to cardiology, where she was immediately started on intravenous heparin (5.1mg/kg every 24h, activated partial thromboplastin time 45.5s), and the surgical and medical teams discussed the need for thrombectomy. After the start of anticoagulant therapy (24–48h), the patient presented acute pulmonary oedema. Urgent echocardioscopy showed severe LV systolic dysfunction (estimated visual LVEF of 15–20%), akinesia in the mid and apical segments, with no sign of apical thrombus. The patient then presented cardiorespiratory arrest, but recovered sinus rhythm after advanced CPR manoeuvres and early defibrillation due to ventricular fibrillation. Emergency thoracoabdominal CT scan showed a filling defect with a free-floating thrombus measuring 75mm in length in the abdominal aorta extending to the main right renal artery and the proximal segment of the inferior mesenteric artery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). We also observed splenic and left renal infarctions, and absence of right renal perfusion caused by the thrombotic obstruction of the renal artery. At the thoracic level, the scan showed bilateral pleural effusion and collapse of both lower pulmonary lobes, without images compatible with pulmonary thromboembolism at any level.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The patient was sent for emergency vascular surgery involving thrombectomy of the superior mesenteric, aorto-iliac, iliofemoral and femoropopliteal arteries, during which a large amount of thrombotic material was extracted. Macroscopic findings of small bowel ischaemia were observed during surgery, so a new arteriotomy of the thrombosed superior mesenteric artery was performed using a horizontal incision to extract the thrombus. The incision was closed with a biological patch. Intestinal perfusion improved, and after an evaluation by general surgery a wait and see approach was decided. On arrival at the ICU the patient presented considerable haemodynamic instability, and was given maximum-dose noradrenaline and intravenous dobutamine. She then presented multiorgan failure, which was treated with renal replacement therapy with ultrafiltration, despite which she progressed to fulminant sepsis within 6h and died.The formation of a large left ventricular thrombus (LVT) is considered an infrequent and very serious complication of ischaemic heart disease, particularly in the context of an acute myocardial infarction. The clinical relevance of this complication is the increased risk of the thromboembolism migrating to the arterial<a class="elsevierStyleCrossRef" href="#bib0030">1</a> system, including the abdominal aorta.<a class="elsevierStyleCrossRef" href="#bib0035">2</a>Guidelines currently recommend treating LVT with anticoagulation agents. This is questioned by some groups. For example, Lee et al.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> evaluated various therapeutic LVT strategies (anticoagulation, antiplatelet therapy, or surgical treatment) in 62 patients with LVT over a mean follow-up period of 24 months, the longest to date. Their results show that high embolic risk patients (female sex, previous cerebrovascular disease, large, multiple, pedunculated or highly mobile thrombi, and increased left ventricular diastolic diameter) could benefit more from surgical thrombectomy than medical treatment: a greater number of post-treatment embolic events and a higher rate of bleeding were observed in the medical treatment group.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> Some authors have suggested that thrombectomy using the left atriotomy approach, extracting the thrombus through the mitral valve, could be an alternative to conventional ventriculotomy in patients with large, mobile pediculated thrombi, and would avoid deterioration of the LV function that is associated with ventriculotomy.<a class="elsevierStyleCrossRef" href="#bib0040">3</a>Leick et al., on the other hand, showed that high-dose intravenous heparin resolved 83% of cases of mobile, protruding thrombi.<a class="elsevierStyleCrossRef" href="#bib0045">4</a> Finally, groups with experience in fibrinolysis have shown this technique to be a promising therapeutic option in these cases. Other authors, in contrast, have reported embolic events after fibrinolysis.<a class="elsevierStyleCrossRef" href="#bib0045">4</a>There is currently no consensus on the best therapeutic strategy in these cases; however, our experience and that of several other authors,<a class="elsevierStyleCrossRefs" href="#bib0045">4,5</a> suggests that surgical thrombectomy is probably the best first-line therapy in patients with large, pedunculated, mobile thrombi that are typically associated with high embolic risk. The management of intraventricular thrombi, therefore, is a medical-surgical emergency, where speed and aggressive action are key to mitigating the high risk of mortality in these patients." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Urmeneta Ulloa J, Pérez Guerrero A, Molina Borao I, Fuentes Gorgas F, Miñano Oyarzabal A. Embolismo de trombo ventricular izquierdo gigante hacia aorta abdominal. Rev Esp Anestesiol Reanim. 2018;65:414–416." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0010" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2059 "Ancho" => 1583 "Tamanyo" => 147089 ] ] "descripcion" => array:1 [ "en" => "Modified two chamber apical TEE: (A) left ventricular thrombus (LVT) and (B) SonoVue® contrast showing the giant, pedunculated apical LVT." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2067 "Ancho" => 1583 "Tamanyo" => 289249 ] ] "descripcion" => array:1 [ "en" => "Thoracoabdominal CT: (A) thrombus extending from the abdominal aorta to the right main renal artery and (B) floating thrombus measuring 75mm in the abdominal aorta." ] ] 2 => array:6 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 367739 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "Video 1 Four chamber apical TTE. Sub-optimal transthoracic window. Difficult visualization of the left ventricular apical thrombus." ] ] 3 => array:6 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 248274 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "Video 2 Parasternal TTE. Sub-optimal transthoracic window." ] ] 4 => array:6 [ "identificador" => "upi0015" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 339496 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "Video 3 TEE with SonoVue® contrast. 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ISSN: 2341-1929

Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Revista Española de Anestesiología y Reanimación has received its first journal Impact Factor (JCR) in 2023. Instructions for authors - Submit an article

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Impact factor

The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years.

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Impact factor 2023

0.9

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Citescore 2023

1.8

SJR

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SJR 2023

0.239

SNIP

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field.

SNIP 2023

362

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Vol. 65. Issue 7.

Pages 414-416 (August - September 2018)

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