Thrombus Migration Just before Surgery

An 84-year-old woman was diagnosed with cardiogenic shock requiring emergent percutaneous coronary intervention. After emergency percutaneous coronary intervention, transthoracic echocardiography indicated a 30-mm mobile thrombus with the largest diameter of 35 mm in the left atrium (panel A). She was induced for urgent left atrial thrombectomy. Transesophageal echocardiography revealed that the left intra-atrial thrombus had migrated into the left ventricle passing through the aortic valve (panel B and Supplemental Digital Content video 1, https://links.lww.com/ALN/D62). Considering the size of the thrombus and the likelihood of entering carotid arteries, vascular echography was immediately performed and revealed a thrombus in the right common carotid artery. However, cerebral oximetry indicated that oxygen saturation decreased gradually from 77 to 62% in 30 min on the right side versus a constant reading of 40% on the left side. The atrial thrombectomy was abandoned, and an endovascular thrombectomy was performed instead, which confirmed the diagnosis. We believe that continuously monitoring the presence and/or migration of a large intracardiac thrombus is critical because the management of such a patient may be changed promptly. In addition, the reduction in cerebral oximetry reading was important for determining the laterality of the carotid-cerebral vasculature, but not reliable because it is dependent on the insufficiency of collateral flow.¹  Therefore, the observed disappearance of an intracardiac large thrombus should be investigated in a timely matter to guide the management of the patient. Ultrasound can be used to quickly identify the possible location of the thrombus. This leads to reduction of time to intervention, which is significantly associated with improved outcomes.²