Alternative Approach to Left Ventricular Thrombectomy Using Percutaneous Cardiopulmonary Bypass: A Case Report

Traditional bypass methods for intracardiac thrombectomy may require direct manipulation of the heart, which carries the potential for increased stroke risk from either arrhythmias or direct dislodgement and embolization of a thrombus. Currently, there is very little research regarding the different ways to approach cardiopulmonary bypass in thrombectomy cases. This case study highlights the use of percutaneous femoral access cardiopulmonary bypass (PCPB) in the management of a large, mobile, left ventricular thrombus (LVT) in a patient with a recent stroke. In this case, a 49-year-old male with a history of an anterior wall myocardial infarction and subsequent percutaneous coronary intervention (PCI) presents now, four years later, with shortness of breath. At the time of his initial presentation, he was documented to have anterior wall akinesis and a mobile LVT. Warfarin was recommended at that time, but the patient was noncompliant. Before further workup could be completed, the patient experienced a cerebrovascular accident (CVA), but after a comprehensive workup, he was cleared for surgery two days later. The patient required surgery for apical thrombus removal and ventricular reconstruction. Following sternotomy and initiation of percutaneous cardiopulmonary bypass, an apical infarct and thrombus were identified and removed via left ventriculotomy. Purse-string sutures were placed to exclude scar tissue and restore ventricular shape, and the ventriculotomy was closed using a modified Dor procedure. The patient was successfully weaned off bypass. The patient was discharged on postoperative day 12 with normalized labs, showed excellent functional recovery, remained symptom-free at two months, and remained stable without complications at eight months. The "no touch" approach provided by percutaneous bypass minimizes the risk of complications such as a stroke, suggesting its consideration as a standard of care during left ventricular thrombectomy. This case encourages further research into PCPB as a preferable alternative to traditional bypass methods in managing left ventricular thrombi, especially in high-risk embolization scenarios.