Surgical management of left ventricular masses: a case series highlighting ventricular-sparing approaches

Left ventricular (LV) masses, ranging from neoplasms to thrombi, pose diagnostic challenges and significant embolic risks. The traditional surgical approach often involves a ventriculotomy, which can contribute to compromised myocardial function. In the present case series, we aim to report three patients with LV masses of different etiologies managed surgically at a tertiary care center. In the first case, a suspected myxoma attached to the anterior papillary muscle was excised via a trans-mitral approach. Histopathology revealed a rare non-valvular papillary fibroelastoma. In the second case, the patient presented with ischemic cardiomyopathy (left ventricular ejection fraction (LVEF) 40%) and a small apical thrombus, which was managed via a trans-aortic approach, allowing extraction through the aortic valve to preserve ventricular geometry. The third case was a patient with ischemic heart disease (post-percutaneous coronary intervention (post-PCI)) and severe LV dysfunction (LVEF 30%) who presented with a massive (5 × 4 cm) anterior wall thrombus. Access was achieved via the trans-mitral route, facilitating complete extraction of the large burden without ventriculotomy. In this series, we suggest a tiered approach toward LV masses depending on the mass size, location, and patient hemodynamics. Utilizing natural valve orifices (trans-atrial and trans-aortic) to avoid ventriculotomy, particularly in patients with compromised ejection fractions, may improve surgical outcomes by preserving ventricular physiology.