Anesthetic Challenges in Emergency Surgery for Left Ventricular Thrombus with Mesenteric Ischemia A Rare Case Report

Introduction

Left ventricular thrombus (LVT) is a potentially life-threatening complication, often following acute coronary syndromes or severe non-ischemic cardiomyopathy. Although its incidence has declined with advances such as primary percutaneous coronary intervention, it still poses significant perioperative challengesespecially during emergency non-cardiac surgeries.

This case, published in the International Journal of Clinical Anesthesia Research, details the anesthetic management of a 30-year-old male with LVT and superior mesenteric artery (SMA) thrombosis requiring emergency laparotomy. The complex interplay of cardiac instability, embolic risk, and urgent surgical intervention highlights the need for meticulous planning and monitoring.

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Case Overview & Clinical Presentation

• Patient profile: 30-year-old male, ~50 kg
• Symptoms: 3-week history of intermittent abdominal pain, vomiting, diarrhea, and dyspnea on exertion (NYHA Class III)
• Investigations:
  • CECT abdomen: Superior mesenteric artery thrombosis
  • Echocardiography: Global hypokinesia, EF < 30%, apical LVT
  • ECG: T-wave inversion in all leads, LV hypertrophy
• Diagnosis: Acute mesenteric ischemia secondary to thromboembolic LVT

Key Clinical Risks:

• High perioperative risk of arrhythmia, stroke, or cardiac arrest
• Limited time for anticoagulation prior to emergency surgery
• Potential for intraoperative hemodynamic instability

Read the full study at https://doi.org/10.29328/journal.ijcar.1001028

Perioperative Anesthetic Management

Preoperative Preparation

• Continuous heparin infusion (stopped 1 hour before surgery)
• Blood products reserved (PRBC, FFP, platelets)
• Invasive monitoring: Right radial arterial line & right internal jugular central line under ultrasound guidance

Induction & Maintenance

• Induction agents: Fentanyl, midazolam, etomidate, atracurium
• Ventilation: Controlled ventilation with oxygen, nitrous oxide, and isoflurane (MAC 0.5–1.0)
• Analgesia: Paracetamol and intermittent fentanyl
• Precautions: Avoided tachycardia, hypotension, and excessive inotrope use to reduce clot embolization risk

Surgical Findings & Outcome

• Intraoperative: Gangrenous jejunal segment (~70 cm) resected
• Blood loss: ~200 ml
• Duration: 2 hours, uneventful
• Postoperative: ICU care with heparin infusion restarted; extubated on day discharged on dual antiplatelets and anticoagulants

Discussion & Broader Implications

LVT can arise post-myocardial infarction or due to severe LV dysfunction in non-ischemic cardiomyopathies. The American Heart Association emphasizes early diagnosis and aggressive anticoagulation to prevent systemic embolization, which may present as limb or mesenteric ischemia.

In acute mesenteric ischemia, every 6-hour delay in diagnosis doubles mortality. Anesthetic goals include:

• Avoiding sudden hemodynamic shifts
• Preventing embolization by maintaining stable cardiac output
• Ensuring adequate volume status without overloading the compromised ventricle

A detailed analysis can be found in our main journal article.

Conclusion & Key Takeaways

• LVT with SMA thrombosis is a rare but critical surgical emergency.
• Multidisciplinary coordination between anesthesia, surgery, and cardiology teams is essential.
• Long-term anticoagulation and follow-up are mandatory due to lifelong embolic risk.

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