On-Pump Coronary Artery Bypass Grafting With Concomitant Transaortic Left Ventricular Thrombectomy in a Patient With Severe Ischemic Cardiomyopathy and Viable Myocardium: A Case Report

Left ventricular (LV) thrombus is a recognized complication of severe ischemic cardiomyopathy and carries a substantial risk of systemic thromboembolism.Standard management is anticoagulation over four to eight weeks to allow clot resolution; however, this delays treatment of concurrent coronary arterial disease.In this patient, the severity of the triple-vessel coronary arterial disease prompted early intervention.We describe a combined on-pump surgical strategy in which cardioplegic arrest was used specifically for embolic protection, enabling simultaneous revascularization and thrombus removal.A 66-year-old man with diabetes mellitus, hypertension, ischemic heart disease, and severe left ventricular (LV) dysfunction (LV ejection fraction (LVEF) = 23%) presented with four months of exertional dyspnea and chest discomfort.Coronary angiography demonstrated calcific triple vessel disease with total occlusion of the left anterior descending (LAD) and left circumflex (LCx) arteries and a 95-99% right coronary artery (RCA) lesion.Fluorodeoxyglucose-positron emission tomography (FDG PET) showed extensive hibernating myocardium, supporting revascularization.An echocardiogram obtained 13 days after a clot-free study revealed an 18×14 mm mobile LV apical thrombus.The patient underwent on-pump coronary artery bypass grafting (CABG; three grafts) with transaortic LV thrombectomy.To avoid the embolic risk of off-pump cardiac manipulation, cardiopulmonary bypass and cardioplegic arrest were established before the heart was handled, and the thrombus was removed transaortically under direct visualization of the arrested heart.Recovery was uneventful, and a postoperative day 3 echocardiogram confirmed clot resolution.At the threeweek follow-up (postoperative day 21), the patient was clinically well with no recurrent thrombus and improvement in LVEF to 35-40%.This case suggests that an on-pump, arrested-heart approach can provide effective embolic protection when CABG and LV thrombectomy are performed in a single setting, and that FDG PET viability assessment can support high-risk revascularization in severely depressed LV function.In patients with severe coexisting coronary disease, early surgical clot removal may be preferable to awaiting clot dissolution on anticoagulation.