Left ventricular mass: intraoperative transesophageal echocardiography for evaluation and management.

A 29-yr-old obese man with recent embolic stroke was brought to the operating room for resection of presumed intracardiac neoplasm suggested by preoperative imaging, including transthoracic echocardiography and cardiac magnetic resonance imaging. A significant history of cocaine use was revealed before surgery. The intraoperative transesophageal echocardiography (TEE) examination revealed mildly decreased left ventricular (LV) function (ejection fraction 45%) and confirmed a 25 15 mm mobile, pedunculated mass in the LV attached near the apex. A combination of mid-esophageal and transgastric views were used to image the mass, which was homogenous, noncalcified and noncavitated with higher echogenicity relative to myocardial tissue (Figs. 1 and 2). Regional wall motion abnormalities that were not described on initial studies were observed in the apex near the point of attachment of the mass. The apical anterior region was dyskinetic at the site of attachment with hypokinesis of the apical septal, lateral, and inferior segments (Video loop 1; please see video clip available at www.anesthesia-analgesia.org). The preoperative diagnosis of neoplasm was reconsidered in light of the regional wall motion abnormalities and the patient’s substance abuse history. A presumptive diagnosis of postmyocardial infarct (MI) associated thrombus was made, although the presence and extent of coronary artery disease had not yet been evaluated with coronary angiography. If significant coronary artery disease was present and coronary artery bypass grafting was indicated, a revascularization procedure could be performed at the time of thrombectomy. For this reason, the procedure was postponed and coronary angiography was performed the following day. This study demonstrated nonobstructive disease with luminal irregularities in the left anterior descending artery, consistent with the wall motion abnormalities observed by TEE. Although coronary revascularization was not indicated, thrombectomy was performed due to a high level of concern regarding additional embolic events. The procedure and postoperative course were uneventful; surgical pathology of the specimen confirmed the diagnosis of infarcted myocardium with associated thrombus. Echocardiography (transthoracic and TEE) remains the imaging modality of choice in the initial assessment of cardiac sources of emboli. In formulating the differential diagnosis of an intracardiac mass, the examiner must evaluate the size, shape, mobility, location, and myocardial attachment or infiltration in addition to considering the overall clinical scenario. Although pathologic intracardiac masses can be due to infectious processes or malignancy, thrombus is a common intraventricular mass. LV thrombi are usually located in the apex in association with an infarcted region. LV tumors tend to be intramural rather than pedunculated, and may alter the echogenic properties and regional contractile function of the tissue. Although LV thrombus was historically a frequent complication of MI, occurring in 20%– 60% of patients, the incidence has substantially decreased to approximately 4.3% since the advent of thrombolytic therapy and percutaneous interventions. Most thrombi develop within the first 14 days after an MI This article has supplementary material on the Web site: www.anesthesia-analgesia.org.