Author + information
- Dan Nguyen, MD,
- David Ellison, MD,
- Christian Ngo, MD,
- Zachary Steinberg, MD,
- Creighton Don, MD, PhD and
- Richard K. Cheng, MD, MSc∗ ()
- Division of Cardiology, Department of Internal Medicine, University of Washington Medical Center, Seattle, Washington
- ↵∗Address for correspondence:
Dr. Richard K. Cheng, Division of Cardiology, Department of Internal Medicine, University of Washington Medical Center, 1959 NE Pacific Street, Box 356422, Seattle, Washington 98195-6422.
We describe the management and clinical decision making in a cardiogenic shock patient with a free-floating left ventricular thrombus found during temporary mechanical support with an Impella CP. The management of these patients can be challenging because there are no guidelines or data to support any particular treatment strategy. (Level of Difficulty: Intermediate.)
A 58-year-old man with progressive heart failure from coronary artery disease presented to our facility in cardiogenic shock in the setting of non–ST-segment elevation myocardial infarction for consideration of advanced heart failure therapies.
Transthoracic echocardiogram (TTE) with Definity contrast (perflutren lipid microsphere, Lantheus Medical Imaging, North Billerica, Massachusetts) was performed at baseline, which showed a severely dilated left ventricle (LV) with LV ejection fraction of 10% without mural thrombus (Figures 1A and 1B, Videos 1A, 1B, and 1C). A transfemoral Impella CP (Abiomed, Danvers, Massachusetts) was implanted without complication as a bridge to durable LV assist device. Anticoagulation with systemic heparin and purge solution was initiated with a systemic goal anti-Xa level between 0.3 to 0.5 IU/ml, per institutional standard.
On hospital day 6, the Impella developed incessant suction events. TTE showed an unexpected echodense 4.0 cm-by-1.5 cm thrombus floating freely between the left atrium and LV (Figures 1C and 1D, Videos 2 and 3). The patient suddenly developed dysarthria and right-sided facial droop during TTE acquisition, and was found to have large left M1 distribution stroke on computed tomography imaging. During this time, the Impella continued to suction without providing adequate hemodynamic support.
The decision was made to remove the Impella and place an intra-aortic balloon pump, while deploying a Sentinel cerebral protection device. Leaving the Impella traversing the aortic valve offered the benefit of providing temporary LV outflow tract “obstruction” to prevent the thrombus from embolizing (Video 4). However, this solution was temporary because the dysfunctional Impella could lead to thrombus propagation if not removed. The residual intraventricular thrombus likely embolized at the time of Impella removal, because repeat TTE no longer visualized the thrombus (Figures 1E and 1F). A second stroke may have been prevented in our patient by the Sentinel device.
The existing published reports on managing free-floating LV thrombi are limited to small case series in which patients with pedunculated LV masses and cardiogenic shock undergo LV ventriculotomy and thrombectomy with concomitant LV assist device implantation (1). The free-floating thrombus would likely have embolized before our patient could undergo surgery, leading to a futile operation. Another option considered was apical LV puncture with aspiration thrombectomy, but this would likely cause shearing and showering of clot fragments distally and further stroke. Tissue plasminogen activator was not an option as the patient was on systemic heparin and had a prohibitively high risk of hemorrhagic conversion.
In summary, the management of free-floating intraventricular thrombi is challenging, with no data to support an optimal treatment strategy. A conservative approach where the Impella is removed with concomitant Sentinel device deployment may be considered.
Dr. Steinberg has been a consultant for Medtronic and Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page.
- Abbreviations and Acronyms
- left ventricle
- transthoracic echocardiogram
- Received March 20, 2020.
- Accepted April 21, 2020.