A woman in her 60s was brought to the previous hospital with respiratory distress. She was referred for the treatment of severe cardiac dysfunction and a mobile mass in the left ventricle. Echocardiography revealed the mass to be of 20×11 mm in size, mobile and slightly attached to the left ventricle by a stalk. As MRI had already revealed a small cerebral infarction, we have decided to perform emergency thrombectomy of the left ventricle. As the left ventricular contractility was diffusely impaired, we were able to remove the mass without any residuals using a transseptal approach without a left ventricular incision using a three-dimensional microscope system. The pathological diagnosis of the mass was thrombus, and subsequent close examination led to the diagnosis of cardiac sarcoidosis. We report the surgical technique and removal of a left ventricular thrombus complicated by cardiac sarcoidosis.
- Cardiothoracic surgery
- Cardiovascular medicine
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Sarcoidosis is a systemic granulomatous disease of unknown aetiology. In particular, cardiac sarcoidosis causes fatal arrhythmias and severe heart failure, which can lead to sudden death and greatly affect the prognosis of patients with sarcoidosis. Only few case reports of left ventricular thrombus complicated by cardiac sarcoidosis are available, and removal of the left ventricular thrombus when cardiac function is compromised requires careful consideration of the approach.
A woman in her 60s, with no specific medical history, had been admitted to another hospital for acute heart failure.
As the transthoracic echocardiography revealed severe cardiac dysfunction and a mobile mass in the left ventricle, and MRI revealed a cerebral micro infarction, the patient was transported to our hospital for further management. A 12-lead ECG showed a first-degree atrioventricular and complete right bundle branch blocks. Transthoracic echocardiography showed a left ventricular end-diastolic diameter of 48.0 mm, end-systolic diameter of 39.4 mm, ejection fraction of 30% and a 20×11 mm mobile stalked mass in the left ventricular apex (figure 1). Thinning of the base of the interventricular septum was also observed. Cardiac CT revealed no significant coronary artery stenosis or bilateral hilar lymphadenopathy. Blood investigations, performed on suspicion of sarcoidosis, showed normal ACE levels and elevated lysozyme and soluble interleukin-2 receptor levels.
As the patient had a large, mobile mass in the left ventricle and had already developed an embolism, we decided to perform an emergency left ventricular thrombectomy. Due to the undetermined cause of the low cardiac function, an intra-aortic balloon pump was inserted before surgery. A median sternotomy was performed, cardiopulmonary bypass was initiated by draining deoxygenated blood from the bilateral vena cava and transfusion of oxygenated blood in to the ascending aorta, and a vent tube was inserted into the left atrium via the right upper pulmonary vein. After aortic cross-clamping, cardiac arrest was induced using antegrade cardioplegia. The right atrium was incised, and the left ventricle was reached over the mitral valve via a transseptal approach. We used a three-dimensional (3D) microscope system ORBEYE (OLYMPUS) to observe the left ventricle clearly and in detail. A stalked dark red mass was seen in the left ventricular apex (figure 2), which was removed from the root of the stalk using forceps and tweezers, as confirmed by ORBEYE. After confirming the absence of any remaining mass through meticulous examination with ORBEYE, we proceeded to conduct a biopsy of the myocardium, specifically targeting the area where the mass had adhered, as well as the adjacent ventricular septum. This comprehensive approach ensured the thorough completion of the surgical procedure. ORBEYE was very effective in removing the intraventricular thrombus without any remanence using a transseptal approach, without any additional left ventricular incision.
Outcome and follow-up
Postoperative pathology revealed a platelet thrombus with inflammatory cellular components, and a myocardial biopsy showed no evidence of sarcoidosis. However, a subsequently performed contrast-enhanced MRI showed thinning of the ventricular septal base and delayed contrast at the base and middle of the heart, including some subendocardial areas. Positron emission tomography-CT revealed numerous fluorodeoxyglucose (FDG) hyperaccumulations in the basal septum, lower wall, anterior left atrium, right side of the right atrium, near the pulmonary artery valve and right ventricle as well as many FDG hyperaccumulations in the hilar and mediastinal lymph nodes (figure 3). Skin biopsy revealed sarcoidosis. The patient was discharged 16 days postoperatively and scheduled to receive steroid therapy.
Sarcoidosis is a systemic granulomatous disease of unknown aetiology. In particular, cardiac sarcoidosis causes fatal arrhythmia, severe heart failure and even sudden death, greatly affecting the prognosis of patients with sarcoidosis. Cardiac sarcoidosis accounts for only 2%–5% of systemic sarcoidosis, but its diagnostic difficulties can delay the detection and treatment. It can be fatal because the only clinical manifestations are cardiac symptoms, and the specificity of biomarkers or sensitivity of histological examination of biopsy samples is very low.1 2 Although some reports suggest a relationship between sarcoidosis and pulmonary embolism,3 left ventricular thrombosis due to sarcoidosis is rare. Left ventricular thrombus is usually triggered by stasis of left ventricular blood flow due to low left ventricular function, such as myocardial infarction and enhancement of coagulation factors.4 In this particular case, the formation of the left ventricular thrombus is believed to be a consequence of reduced cardiac function caused by sarcoidosis, leading to a stagnant flow of blood within the left ventricle. Kanemitsu et al reported a case of left ventricular thrombus associated with cardiac sarcoidosis removed by left ventriculotomy5; however, there is no report of a left ventricular thrombus associated with sarcoidosis removed by a transseptal approach using a 3D microscope system. Approaches to the left ventricular thrombus include transaortic and transleft ventricular approaches; however, the transaortic approach has a limited field of view and holds the risk of residual thrombus, while the transleft ventricular approach may result in further deterioration of cardiac function, low output syndrome or bleeding due to left ventricular incision. In this case, a thrombus was found deep in the apex of the left ventricle, and we performed the surgery using a transseptal approach combined with the 3D microscope system ORBEYE. Currently, we are using a 3D microscope system, mainly for minimally invasive cardiac surgery (figure 4). The 3D microscope system displays 4K3D images on a large 55-inch monitor. In this case, we were able to remove the thrombus from the stem without leaving any residue, even at the apex of the left ventricle, under a clear and good field of view shared by all members in the operating room on a 4K3D surgical screen with a 3D microscope system, which was also effective in this case.
We report a rare case of left ventricular thrombus complicated by cardiac sarcoidosis. We successfully and easily removed the thrombus using a 3D microscope without a left ventriculotomy to improve the cardiac function.
I was aware of gradual dyspnoea on exertion in my normal life, but it suddenly worsened. After being rushed to the hospital, I also became aware of numbness in my fingers. I thought I would die and was confused when they suddenly told me it was an emergency surgery. I am glad that the disease was discovered and that the thrombus was safely removed before a major embolism could occur. I would like to do my best to treat them from now on.
Cardiac sarcoidosis significantly affects the prognosis of patients with sarcoidosis.
We report a rare case of left ventricular thrombus complicated by cardiac sarcoidosis.
This case demonstrates successful removal of the thrombus using a three-dimensional microscope without a left ventriculotomy to improve cardiac function.
Patient consent for publication
We would like to thank Editage (www.editage.com) for English language editing.
Contributors Conceptualisation: SW and HM; Data curation: SW and HM; Formal analysis: SW and HM; Funding acquisition: none; investigation: SW; Methodology: SW and HM; Project administration: SW and HM; Resources: SW and HM; Software: SW and HM; Supervision: SM; Validation: DF, HM and SM; Visualisation: SW; Roles/writing–original draft: SW; Writing–review and editing: SW and HM.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.