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Intracardiac Echogenicity During Cardiopulmonary Bypass in a Vasoplegic Patient Undergoing Coronary Artery Bypass Grafting: To Explore or To Ignore

Published:December 26, 2022DOI:https://doi.org/10.1053/j.jvca.2022.12.020
      To the Editor:
      Intracardiac thrombus formation during cardiopulmonary bypass with full heparinization and adequate activated clotting time is uncommon,
      • Kim S-H
      • Ryu J-S
      • Kim T-Y
      • et al.
      Abrupt formation of intracardiac thrombus during cardiopulmonary bypass with full heparinization -A case report.
      ,
      • Kim SY
      • Song JW
      • Jang Y-S
      • et al.
      Formation of intracardiac thrombus during cardiopulmonary bypass despite full heparinization and adequate activated clotting time -A case report.
      but it can be catastrophic given the potential of intracardiac thrombus to embolize and cause stroke, end-organ infarction, and acute limb ischemia.
      • Jeon GJ
      • Song BG
      • Park YH
      • et al.
      Acute stroke and limb ischemia secondary to catastrophic massive intracardiac thrombus in a 40-year-old patient with dilated cardiomyopathy.
      Spontaneous left ventricular thrombus formation during cardiopulmonary bypass in coronary artery bypass grafting is rare. A 62-year-old man with a history of heart failure with progressively declining ejection fraction and multivessel coronary artery disease presented for an elective coronary artery bypass grafting. After removal of the aortic cross-clamp, an echogenicity was seen adjacent to the lateral wall of the left ventricle, concerning for a left ventricular thrombus (Fig 1). The heart was rearrested, and a left atriotomy was created. The surgeon was able to remove the left ventricular thrombus in 2 pieces through the mitral valve (Fig 2). No residual thrombus was observed after cardiopulmonary bypass. The patient was neurologically intact after the surgery, and had a relatively unremarkable postoperative course.
      Fig 1
      Fig 1Transesophageal echocardiography prior to separation from cardiopulmonary bypass showing an echogenicity (circled in red) in relation to the lateral wall of the left ventricle. TEE, transesophageal echocardiography.
      Fig 2
      Fig 2Intracardiac thrombus removed after cardiotomy.
      The underlying etiology of the left ventricular thrombus in this patient was unclear. It is possible that the left ventricular thrombus developed as a result of inadequate left ventricular venting and decompression. The activated clotting time exceeded 400 seconds at all times during cardiopulmonary bypass, so inadequate heparin anticoagulation was unlikely to be responsible for thrombus formation. However, cardiopulmonary bypass is highly thrombogenic, and the thrombin continually produced during cardiopulmonary bypass is only partially suppressed by heparin.
      • Edmunds LH
      • Colman RW.
      Thrombin during cardiopulmonary bypass.
      Lupus anticoagulant tests were positive after surgery, but the patient did not have a history of lupus or thrombosis. The patient was referred to rheumatology for follow-up.

      Conflict of Interest

      None.

      Appendix. Supplementary materials

      References

        • Kim S-H
        • Ryu J-S
        • Kim T-Y
        • et al.
        Abrupt formation of intracardiac thrombus during cardiopulmonary bypass with full heparinization -A case report.
        Korean J Anesthesiol. 2012; 62: 175-178
        • Kim SY
        • Song JW
        • Jang Y-S
        • et al.
        Formation of intracardiac thrombus during cardiopulmonary bypass despite full heparinization and adequate activated clotting time -A case report.
        Korean J Anesthesiol. 2012; 62: 571-574
        • Jeon GJ
        • Song BG
        • Park YH
        • et al.
        Acute stroke and limb ischemia secondary to catastrophic massive intracardiac thrombus in a 40-year-old patient with dilated cardiomyopathy.
        Cardiol Res. 2012; 3: 37-40
        • Edmunds LH
        • Colman RW.
        Thrombin during cardiopulmonary bypass.
        Ann Thorac Surg. 2006; 82: 2315-2322