A 36-yr-old man with a medical history significant for anabolic steroid abuse initially presented to the operating room with aortic valve endocarditis with a focal perforation of the anterior leaflet of the mitral valve secondary to a prolapsing aortic valve vegetation. The patient underwent uneventful aortic valve replacement with a 25 mm On-X (MCRI, Austin, TX) mechanical valve and repair of the mitral valve perforation with a bovine pericardial patch. Throughout the procedure, he received intermittent retrograde cardioplegia via a coronary sinus catheter that was placed without difficulty under transesophageal echocardiography (TEE) guidance in the prebypass period.
The patient’s postoperative course was complicated by persistent high grade fevers and respiratory failure. A repeat TEE examination on postoperative day 10 revealed an ejection fraction (EF) of 45% and multiple echodense masses adherent to both the atrial and ventricular aspects of the patient’s mitral valve. In addition, an elliptical sessile mass was discovered adhering to the lateral wall of the right atrium and impinging on the anterior leaflet of the tricuspid valve. There was moderate tricuspid regurgitation secondary to leaflet restriction. The mechanical aortic valve appeared to be functioning normally. No abnormalities of the coronary sinus were noted at the time.
The patient returned to the operating room for reexploration and debridement of presumed recurrent endocarditis. Intraoperative TEE once again revealed a low normal EF and echogenic masses adherent to the mitral valve (Fig. 1A) and to the lateral wall of the right atrium (Fig. 1B). In addition, a dilated coronary sinus was noted in the midesophageal views (Fig. 1A). Further inspection of the coronary sinus in a modified four-chamber view demonstrated the presence of thrombus with near complete occlusion of the coronary sinus which measured nearly 2 cm in diameter (Figs. 2A and B, Video Clip 1; please see video clips available at www.anesthesia-analgesia.org).
Surgical exploration confirmed the presence of multiple thrombi that did not seem infectious in origin. Examination of the coronary sinus verified complete occlusion of the sinus with thrombus. The patient underwent thrombectomy of the tricuspid valve, mitral valve, and coronary sinus without complication. Postcardiopulmonary bypass TEE demonstrated normal mitral and tricuspid valve function. The postprocedure left ventricular function was markedly improved, with an EF of 65%, compared to 45% before operation (Video Clip 2; please see video clips available at www.anesthesia-analgesia.org). Pathologic examination confirmed noninfectious organized thrombus recovered from the mitral valve, tricuspid valve, and coronary sinus.
The coronary sinus is responsible for the venous drainage of the heart under normal conditions. It receives contributions from the small, middle, oblique and great cardiac veins, courses through the coronary sulcus and empties into the right atrium between the inferior vena cava inlet and the septal leaflet of the tricuspid valve. On TEE examination, the coronary sinus is reliably visualized in a modified midesophageal four-chamber view (with slight insertion and retroflexion of the probe) and in the bicaval view (where it can be seen adjacent to the junction of the inferior vena cava and the right atrium). In one study, the coronary sinus was successfully visualized in 100% of patients using TEE and the mean maximum diameter measured 9 ± 2 mm.1 Coronary sinus dilation may be encountered in patients with persistent left superior vena cava, congenital abnormalities, and elevated right atrial pressures with right atrial dilation.2
Coronary sinus thrombosis, as described in this case, is a rare complication of heart transplantation, infection and coronary sinus instrumentation.3 Case reports in humans suggest that coronary sinus thrombosis can precipitate myocardial infarction and is often fatal.4 Our patient may have been predisposed to thrombus formation due to a hypercoagulable state secondary to chronic infection and anabolic steroid use.5 Additionally, coronary sinus cannulation for retrograde cardioplegia administration during the initial surgery may have resulted in endothelial injury that may have served as a nidus for thrombus formation within the sinus.
Although the clinical course after coronary sinus thrombectomy is unclear, there are reported cases of recovery of ventricular function after coronary sinus thrombectomy.6 The immediate improvement of this patient’s left ventricular EF after separation from bypass suggests that coronary sinus thrombosis and cardiac venous congestion may have played a role in his depressed preoperative EF.
This case demonstrates the utility of intraoperative TEE in the evaluation of patients with intracardiac thrombosis. When intracardiac thrombus is suspected, a complete and comprehensive examination of all structures is mandatory to exclude occult locations and to direct surgical management. When coronary sinus involvement is visualized, surgical exploration and thrombectomy may dramatically improve ventricular function.
The authors wish to thank Mr. Jack Segall for assistance in the preparation of the manuscript.
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