Totally endoscopic trans-mitral removal of a left ventricular apical thrombus through right thoracotomy in a patient with subacute anterior myocardial infarction: a case report

Background Left ventricular thrombosis confers a life-threatening risk of systemic embolism; therefore, it requires prompt intervention. Although anticoagulation is the primary treatment, surgery is indicated in instances of large or/and mobile thrombus or when there is potential for recovery of ventricular contraction. However, standard left ventriculoplasty with thrombectomy carries risks of cardiac dysfunction due to left ventriculotomy. Case presentation A 70-year-old man developed chest pain and vomiting 3 weeks before presenting to our hospital. A chest radiograph showed substantial cardiomegaly and mild pulmonary congestion; N-terminal pro-brain natriuretic peptide (5698 ng/L) was substantially increased, and troponin T (56 ng/L) levels were slightly above reference values. Transthoracic echocardiography showed akinesis of the anteroseptal and apical segments with an ejection fraction reduced to approximately 20%. We diagnosed subacute myocardial infarction and initiated pharmacotherapy. On hospital day 7, coronary angiography revealed a left anterior descending artery lesion with 99% stenosis; percutaneous coronary intervention was successfully performed the next day. That same day, transthoracic echocardiography revealed a large mobile left ventricular apical thrombus without any left ventricular aneurysm, and heparin therapy was initiated. On hospital day 10, three-dimensional computed tomography confirmed the location of an apical thrombus, and we planned a fourth intercostal approach. A thrombectomy was performed on hospital day 11 using an endoscopic trans-mitral approach with a right thoracotomy to avoid a left ventriculotomy. The patient was discharged from intensive care on postoperative day 2 under heparin and warfarin therapy. The subsequent postoperative course was uneventful, and he was discharged on postoperative day 14 with a vitamin K antagonist. At the 6-month follow-up, there was no recurrence of thrombus in the left ventricle and Ejection Fraction had improved to 46%. Conclusions Totally endoscopic thrombectomy via a trans-mitral approach through right thoracotomy was effective for a left ventricular thrombus. When concomitant coronary artery bypass grafting or left ventriculoplasty are not required, this procedure can be an effective option.