Mount Sinai Medical Center-Miami Beach is Florida's largest private, nonprofit teaching hospital focused on providing high-quality care to the diverse community of South Florida through teaching, research, and community advocacy. Established in 1949, our system includes 4,000 employees across 11 medical campuses, 672 beds, 26 operating suites, and 650 specialty care physicians with an additional 160 physicians trained every year.

In such a large protocol-driven, multidimensional hospital center, the process of optimizing patient outcomes in surgery can be lost due to challenges in efficiency and coordination. Here, we demonstrate an example of how proper coordination and multidisciplinary discussion led to the best patient outcome in a high-risk surgical case.

Case details

A 43-year-old male with a PMHx of atrial fibrillation, hypertension, high cholesterol, and type II diabetes mellitus presented to our institution with shortness of breath. He described the onset as sudden, constant, and moderate in severity. However, the patient denied any chest pain, nausea, vomiting, diaphoresis, syncope, or near syncopal episodes. Chest X-ray demonstrated clear lungs, and computed tomography arterial portography (CTAP) demonstrated acute bilateral pulmonary embolism with signs of significant right heart strain. Ultrasound of the lower extremity revealed deep vein thrombi in the right popliteal and posterior tibial veins.

Given this patient's large thrombus risk, young age, and inability to oxygenate, the case was discussed with anesthesia, interventional radiology, and cardiothoracic surgery, who deemed the most appropriate treatment to be minimally invasive thrombectomy and embolectomy with monitored anesthesia care. The cardiothoracic surgeon was kept on standby for the procedure if there was a need for conversion to thrombectomy with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and heparin infusion. At the completion of the procedure, a TTE was performed demonstrating 10 cm cord-shaped, highly mobile thrombus in transit from the right atrium to the left atrium entrapped within a patent foramen ovale with intermittent prolapses into the left ventricle (LV) in diastole. See Figures 1 and 2.

Figure 1:

Transthoracic echocardiogram imaging post percutaneous thrombectomy displaying left ventricular thrombus.

Figure 1:

Transthoracic echocardiogram imaging post percutaneous thrombectomy displaying left ventricular thrombus.

Figure 2:

Intraoperative transesophageal echocardiogram displaying right ventricular thrombus extending into a patent foramen ovale.

Figure 2:

Intraoperative transesophageal echocardiogram displaying right ventricular thrombus extending into a patent foramen ovale.

Multidisciplinary decision-making

The decision was made that the patient was in need of emergent surgical intervention to prevent life-threatening arterial system thromboemboli from the thrombus in transit, and a two-physician verbal emergent consent was performed to proceed with planned awake peripheral percutaneous V-A ECMO cannulation and initiation to remove pulsatility with necessary intubation for sternotomy and open emergent surgical removal of thrombus in transit.

After consent was given, the cardiothoracic surgeon proceeded with completion of the pulmonary embolectomy. A brief period of circulatory arrest was initiated, and the thromboemboli were extracted in fragmented pieces secondary to catheter aspiration thromboembolectomy earlier.

An aortotomy was performed in standard fashion at the sinotubular junction (STJ) and the LV explored via the left ventricular outlet obstruction with no further thromboembolism noted. The heart was filled and an extensive manual cardiac massage of the LV was performed to remove any small thromboembolic disease not noted. The heart was noted to spontaneously return to normal sinus rhythm after a few minutes with no distension noted.

Cardiac function significantly improved; however, a prolonged period of V-A ECMO support proceeded until the TTE demonstrated normal LV function with no evidence of further thromboembolism in transit, closed ASD, no thrombus visualized in pulmonary artery, no significant valvular disease, minimally decreased right ventricle function but adequate for V-A ECMO weaning, and no further thromboembolism in the right side of the heart.

Final thoughts

Our case highlights the importance of multidisciplinary decision-making in surgical cases involving highly complicated patients and the importance of revising anesthesia type perioperatively. Inefficiency in pre-, peri-, and postoperative care could have led to complications that would prolong recovery, aggravate the patient's condition, expose the patient to potential infection, or even cause death. As described in the case, we were able to meet with a member from cardiothoracic surgery, vascular surgery, interventional radiology, and anesthesiology to create a plan of action for the complicated patient. During the case, keeping the cardiothoracic surgeon on standby ensured a smooth transition in case of open surgery. Our case stresses the importance of efficient communication and coordination between the surgical, anesthesia, and interventional radiology team in surgical care.

Vignesh Sankar, BS, Medical student, Nova Southeastern University, College of Osteopathic Medicine, Fort Lauderdale, Florida.

Vignesh Sankar, BS, Medical student, Nova Southeastern University, College of Osteopathic Medicine, Fort Lauderdale, Florida.

Nazir Noor, MD, CA-3 Chief Resident, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, Florida.

Nazir Noor, MD, CA-3 Chief Resident, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, Florida.

Ruben H. Schwartz, DO, CA-3 Resident, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, Florida.

Ruben H. Schwartz, DO, CA-3 Resident, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, Florida.

Jason Hoyos, DO, FASA, Associate Program Director, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, Florida.

Jason Hoyos, DO, FASA, Associate Program Director, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, Florida.