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.