Introduction: Left ventricular (LV) clot is a common occurrence after anterior myocardial infarction in patients with decreased left ventricular ejection fraction (LVEF). (1) We present a case of a patient with a very large LV thrombus in the setting of decreased LVEF and advanced chronic heart failure (CHF) with surgical removal of thrombus and left ventricular assist device (LVAD) implantation as destination therapy.

Case report: A 66-year old female patient with a medical history of advanced CHF due to ischaemic cardiomyopathy after a subacute myocardial infarction of LV anterior wall, and with surgically treated thrombosed abdominal aortic aneurysm and removed right kidney, was admitted to our hosiptal due to worsening of CHF. 3D transthoracic and transesophageal echocardiographic (TTE and TEE) examination revealed a dilated, globally hypokinetic LV (Simpson BP EF 21%), with thinned wall, akinetic apex and a formed LV aneurysm containing a sesile thrombus with dimensions of 32x47mm. Due to advanced CHF, impaired kidney function, diffuse peripheral vascular disease, elevated pulmonary vascular resistance, preserved function of the right ventricle and minimal tricuspid regurgitation, we decided to refer the patient to LVAD implantation as destination therapy coupled with prior thrombectomy. The ventriculotomy was performed on the apex to achieve the best possible site for good visualization of the LV chamber for clot removal, as well as ideal position for the LVAD inflow cannula implantation. The thrombus was removed and the LVAD (HeartMate II) was then successfully implanted. Treatment of LV thrombus in this setting is particularly challenging because the large clot has to be completely removed in order to prevent potential pump thrombosis and systemic embolism. The patient was subsequently discharged home, and three years afterwards she is doing well on LVAD support as destination therapy, without any thromboembolic events.

Conclusion: LVAD implantation can be safely performed with previous surgical removal of a large LV clot without systemic embolism. Meticulous preoperative echocardiographic assessment is essential, and novel echocardiographic modalities such as 3D TTE and TEE are of invaluable importance.