What are the guidelines for surgical intervention in patients with cardiac thrombus?

From the Guidelines

Surgical intervention for cardiac thrombus is recommended for large (>10 mm) non-obstructive prosthetic thrombus complicated by embolism, as stated in the ESC Guidelines 1. The management of cardiac thrombus depends mainly on the occurrence of a thrombo-embolic event and the size of the thrombus.

• Close monitoring by echocardiography and/or cinefluoroscopy is mandatory.
• The prognosis is favourable with medical therapy in most cases of small thrombus (<10 mm).
• A good response with gradual resolution of the thrombus obviates the need for either surgery or fibrinolysis.
• Fibrinolysis is less likely to be successful in mitral prostheses, in chronic thrombosis, or in the presence of thrombus.
• Management of left-sided non-obstructive prosthetic thrombosis is as follows:
  • Optimize anticoagulation for non-obstructive thrombus.
  • Follow-up with clinical and echo evaluation.
  • Consider surgery or fibrinolysis if there is persistence of thrombus or thromboembolism. The American College of Chest Physicians also recommends early surgery for patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm² 1. In patients with mechanical valves, long-term VKA therapy is recommended, with a target INR of 2.5 for aortic valves and 3.0 for mitral or double valve 1. It is essential to balance the risks of surgery, including bleeding, stroke, and mortality, against the threat of thromboembolism when making a decision about surgical intervention for cardiac thrombus.
• The decision to proceed with surgery should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
• Less invasive catheter-based approaches may be considered in high-surgical-risk patients, though these techniques remain investigational in many centers. The primary approach involves surgical thrombectomy, particularly for large, mobile thrombi in the left atrium or ventricle, or those attached to prosthetic valves, as recommended by the European Heart Journal 1. Before surgery, patients typically receive anticoagulation with heparin, and the surgical procedure involves cardiopulmonary bypass, careful removal of the thrombus, and inspection of cardiac chambers to ensure complete removal. Post-operatively, patients require long-term anticoagulation, typically with warfarin or direct oral anticoagulants like apixaban or rivaroxaban.

From the Research

Guidelines for Cardiac Thrombus Surgery

The guidelines for surgical intervention in patients with cardiac thrombus are based on various studies that have investigated the optimal treatment strategies for this condition.

• The decision to perform surgery depends on several factors, including the size and location of the thrombus, the patient's overall health, and the risk of embolization 2, 3.
• Early surgical intervention may be recommended for patients with large or mobile thrombi, as it can help prevent further embolization and improve outcomes 3.
• Surgical techniques, such as thrombectomy, may be used to remove the thrombus, and additional procedures, such as bypass surgery, may be necessary in some cases 3, 4.
• The use of mechanical thrombectomy devices and pharmacomechanical thrombectomy strategies may also be considered as alternative treatment options 5, 6.
• The choice of treatment approach should be individualized based on the patient's specific needs and circumstances, and a multidisciplinary team of healthcare professionals should be involved in the decision-making process.

Considerations for Surgical Intervention

Several factors should be considered when deciding whether to perform surgical intervention for cardiac thrombus, including:

• The risk of embolization and the potential consequences of further embolic events 2, 3
• The size and location of the thrombus, as well as its mobility and composition 3, 4
• The patient's overall health and medical history, including any underlying conditions that may affect the risk of surgery 2, 3
• The availability and potential benefits of alternative treatment options, such as thrombolytic therapy or mechanical thrombectomy 2, 5, 6

Outcomes and Complications

The outcomes and complications of surgical intervention for cardiac thrombus can vary depending on several factors, including:

• The success of the surgical procedure in removing the thrombus and preventing further embolization 3, 4
• The risk of operative mortality and morbidity, including complications such as bleeding, infection, and stroke 3
• The potential for long-term consequences, such as postphlebitic syndrome or chronic venous insufficiency, particularly in patients with venous thromboembolism 6