Robotic transmitral resection of floating left ventricular thrombus

Robotic transmitral resection of floating left ventricular thrombus | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Robotic transmitral resection of floating left ventricular thrombus Paul Cullen, Nai-Kuan Chou, Ling-Yi Wei, Hsi-Yu Yu, Nai-Hsin Chi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5667084/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Apr, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Background Despite the role of surgery in the management of left ventricular (LV) thrombi remaining controversial, robotic LV thrombectomy has emerged as a viable treatment option. This study aimed to present our successful experience with a robotic mitral program, detailing the operative technique. Materials and Methods We conducted a retrospective analysis of our institutional database to identify patients who underwent LV thrombectomy using the da Vinci robot system. Subsequently, serial echocardiograms and short- and long-term outcomes were reviewed and analyzed using descriptive statistics. Results A total of five patients (median age: 46 years) were included in this study. All patients presented with a floating LV thrombus and a history of embolization. Among them, four patients experienced reduced heart function, none had coronary artery disease, three experienced dilated cardiomyopathy. Complete resection was achieved in all cases, with no postoperative deaths, strokes, or major complications. Additionally, LV function showed improvement during follow-up periods. Postoperative anticoagulation was continued for two years in one patient and one year in the remaining patients. No recurrence or further embolic events were observed during the median follow-up period of 6 years. Conclusion Robotic LV thrombectomy yields excellent outcomes and should be considered early for patients with floating LV thrombi. However, further investigation is warranted to determine the optimal timing of this intervention and its role in the treatment paradigm, including whether these results can be extrapolated to patients with other forms of mobile thrombus and/or to support surgery as the primary prevention of systemic embolization. Robotic left ventricular thrombectomy Floating thrombi Robotic transmitral approach Left ventricular thrombectomy Surgical thrombectomy Figures Figure 1 Figure 2 Figure 3 Introduction The role of surgery in managing left ventricular thrombi remains controversial to date. While anticoagulation is generally preferred, alternative approaches are considered for refractory cases. Despite the American Heart Association (AHA) emphasizing the lack of evidence against the non-recommendation of surgery,( 1 ) surgical intervention has emerged as a valuable option in cases involving mobile thrombi, especially those “floating” and adhering solely to the left ventricular (LV) trabeculae. However, in such cases, the risk of embolization is increased, particularly among individuals who have previously experienced cerebral events. Moreover, these patients often experienced functional limitations due to their condition, making surgeons hesitant to pursue traditional approaches like sternotomy and left ventriculotomy. To address these challenges, robotic techniques have been employed to access the left ventricle via the left atrium and mitral valve. Given the superior visualization and dexterity offered by robotic technology, we contend that it represents the optimal approach for surgical LV thrombectomy and may warrant broader adoption. This study aimed to present our experience with a surgical technique derived from our highly successful robotic mitral program.( 2 ) Material and Methods Study Design and Patients This retrospective observational cohort study was conducted at our University Hospital on patients who underwent LV thrombus resection within our robotic cardiac surgery program from January 2012 to October 2023. (The study is approved by IRB 202401213RINC). Surgical Technique (Fig. 1, 2 ) All procedures were performed using the da Vinci Si or Xi robot (Intuitive Surgical, Sunnyvale, CA, USA) and based on our extensive experience with robotic mitral valve surgery.( 2 ) Patients were positioned with slight elevation of the right side, the right arm extended behind the posterior axillary line, the right leg everted, and the table rotated leftward. Anesthetic lines were placed in the right radial artery and internal jugular vein (RIJV) with a single-lumen endotracheal tube. Following skin preparation and draping, percutaneous access to the RIJV close to the clavicle, right common femoral vein (RCFV), and right common femoral artery (RCFA) was achieved using ultrasound guidance. Pre-closure of the RCFA was performed with two PerClose Proglides (Abbott, Plymouth, MN, USA). A 3 cm working port in the right 4th intercostal space (ICS) was created, and an XS Alexis (Applied Medical, Rancho Santa Margarita, CA, USA) soft-tissue retractor was inserted without a rib spreader. Subsequent ports were placed in the following sequence: right arm via the 6th ICS, left atrial (LA) retractor via the 4th ICS midway between the midclavicular line and sternal edge, camera via the 4th ICS just medial to the working port, left arm via the 3rd ICS, and a non-robotic port in the 4th ICS posteriorly for later passage of a pericardial stay suture and drop vent sucker. After confirming hemostasis, heparin was administered, and cannulation was performed in the following order: RCFA, RCFV into the inferior vena cava (IVC), and RIJV into the superior vena cava under transesophageal echocardiography guidance after bypass initiation. The robot was docked, and the pericardium was opened anteriorly 1 cm from the sternum, extending superiorly towards the IVC and the lateral pericardial reflection of the aorta. Pericardial stays were placed at either end and removed through the posterior 4th ICS port with a tiny stab incision in the 5th ICS posteriorly to create a “platform” of the pericardium and ensure the lung was kept out of the way. Following the pericardium opening, a long shaft cardioplegic needle was used on the aortic root, and a detachable aortic clamper (Glauber clamp, Cardio Medical GmbH, Langenhagen, Germany) was inserted through the working port into the thoracic cage. Afterward, antegrade cardioplegia (St. Thomas Hospital No. 2, HTK, and adenosine) was administered. The left atrium was opened with monopolar curved scissors, and the LA retractor was positioned to provide excellent visualization of the left ventricle and pathology (Fig. 1). This, combined with the dexterity of the robotic arms, facilitated the retrieval of the thrombus with relative ease and ensured complete resection (Fig. 2D,E). A small endomyocardial biopsy was performed over the apex to confirm the final pathological findings and assess thrombus etiology (Fig. 2F). Following de-airing, the LA was closed in two layers using a 4-O Goretex suture, the antegrade cannula was removed, and the cannulation site was sutured. If hemostasis was deemed satisfactory, the patient was gradually weaned off the bypass during the closure of the pericardium and wounds. Data Collection and Analysis Patient data were retrieved from the Robotic Cardiac Surgery Registry and the hospital's electronic medical records. Numerical data were expressed as means ± standard deviation, and frequencies of simple events were expressed as percentages. All statistical analyses were performed using Microsoft Excel. Results Patient characteristics are summarized in Table 1 . We identified five consecutive patients with a median age of 46 years (range: 36–63 years). Indications for surgery in all patients included “floating” LV thrombus without a significant mural attachment and a history of systemic embolization. Three patients experienced transient ischemic attacks (TIAs), one had a stroke (patient 2), and one presented with brachial artery occlusion (patient 4) (Fig. 3). It is worth mentioning that despite preoperative anticoagulant administration, thrombus persistence was observed in all patients. Table 1 Patients’ characteristics Gender Emboli event Age Pre-operation Cardiac function LVEF % LVIDd (cm) LVISd (cm) LV thrombus (cm) 1 M TIA 46 35 5.0 4.2 1.4×1.6 0.8×0.9 2 F Right temporal infarction, right side weakness, resolved 49 45 5.3 4.0 1.2×1.3 3 M TIA 36 62 4.9 3.8 1.0×0.8 4 F Right brachial artery occlusion 39 46 5.1 4.3 1.2×0.9 5 F TIA 62 42 5.3 4.2 1.1×0.6 0.5×0.5 Abbreviations: TIA, Transient ischemic attack Although none of the patients had coronary artery disease, four had reduced LV function. Complete resection was successfully achieved with a single cardiopulmonary bypass in all patients, confirmed through an intraoperative TOE. No conversions to alternative approaches or postoperative deaths, strokes, or major complications were reported. Anticoagulation was initiated with subcutaneous prophylactic heparin, followed by coumadin on day 1. The mean time to achieve therapeutic anticoagulation/ international normalized ratio (INR) was 3 days, reaching the targeted INR of 2–3 by day 5. Postoperatively, anticoagulation was continued for two years in the first patient and for one year in the remaining patients. Histopathological examinations of LV biopsies taken intraoperatively revealed dilated cardiomyopathy in three patients, while no specific abnormalities were identified in the remaining two. Postoperative medications included anticoagulation and goal-directed medical therapy for heart failure, if necessary. Notably, LV function improved in all patients during follow-up. All patients remained alive without LV thrombus recurrence or further embolic events during a median follow-up of 6 years (range: 4–9 years), with no bleeding complications reported (Table 2 ). Table 2 Post-surgery outcomes Post-surgery cardiac function LVEF % LVIDd (cm) LVISd (cm) Thrombus in LV Pathology findings Anticoagulation duration year Follow up time year Emboli events after surgery 1 56 4.3 3.1 Nil Compatible with DCM 2 9 Nil 2 48 4.8 3.7 Nil Compatible with DCM 1 7 Nil 3 63 4.9 3.5 Nil No specific finding 1 6 Nil 4 50 5.0 3.8 Nil No specific finding 1 6 Nil 5 48 4.8 3.9 Nil Compatible with DCM 1 4 Nil LVEF: left ventricular ejection fraction, LVIDd: left ventricular internal diameter in diastolic phase, LVISd: left ventricular internal diameter in systolic phase, LV: left ventricle, DCM: dilated cardiomyopathy. Discussion LV thrombus poses a significant risk of embolization, observed in up to 22% of cases,( 1 ) resulting in various complications such as coronary,( 3 ) cerebrovascular, renal, bowel, splenic, or lower-limb ischemia, or even complete aortic occlusion.( 4 – 6 ) This condition carries a high mortality rate, with over 10% of patients dying within one year of diagnosis( 7 ). Historically, myocardial infarction was the primary cause, resulting in hypokinetic, akinetic, or dyskinetic aneurysmal segments, most frequently affecting the apex. However, with the advent of rapid coronary angiography and stenting, the incidence following ST-elevation myocardial infarction (STEMI) treatment via percutaneous coronary intervention (PCI) has reduced to 1.6%.( 8 ) Uncommon etiologies, such as blunt trauma-induced left anterior descending (LAD) injuries, have also been reported.( 9 , 10 ) Non-ischemic causes of heart failure can also lead to LV thrombus, including Takotsubo syndrome,( 11 – 13 ) peripartum cardiomyopathy,( 14 , 15 ) hypertrophic cardiomyopathy,( 16 ) sarcoidosis,( 17 ) Churg-Strauss syndrome,( 18 ) anabolic steroid use,( 19 ) LV non-compaction,( 20 ) pediatric myocarditis,( 21 ) and multisystem inflammatory syndrome in children (MIS-C) associated with Covid-19.( 22 ) Specifically, the reported incidence of LV thrombosis in dilated cardiomyopathy varies widely, ranging from 2–36%.( 1 ) Additionally, LV thrombus can also occur in patients with normal ventricular function, as observed in one of our cases.( 7 , 23 ) However, while procoagulant or proinflammatory conditions such as thrombophilia,( 24 ) hypereosinophilia,( 5 , 25 ) antiphospholipid syndrome,( 26 , 27 ) human immunodeficiency (HIV) disease,( 28 ) Crohn’s disease,( 29 ) and ulcerative colitis( 30 ) are frequently implicated, the etiology remains unknown in some cases. Moreover, research has suggested severe dehydration as a potential contributing factor.( 31 ) LV thrombus can complicate valvular pathology, such as aortic stenosis, regardless of normal( 32 ) and abnormal( 33 ) ventricular function. Dense mitral annular calcification can also be associated with thrombus formation along the mitral annulus, even in the presence of normal ventricular and valvular function.( 34 ) Additional risk factors include malignancies and chronic renal failure.( 35 ) While symptomatic embolization is a common presentation, fever may be the only symptom,( 36 ) or a thrombus may be incidentally discovered during cardiac imaging. To detect apical thrombus, contrast-enhanced echocardiography is preferred over standard transthoracic echocardiography, and transesophageal echocardiography does not provide additional sensitivity.( 1 ) Despite cardiac MRI being more sensitive and specific than other modalities, it is obviously less convenient; therefore, contrast-enhanced transthoracic echocardiography appears to be the best choice.( 1 ) Thus, subsequent imaging should ideally be performed with a test that is at least as sensitive as the initial diagnostic study( 1 ). The primary treatment for confirmed LV thrombus is anticoagulation, with thrombolysis and surgical thrombectomy being alternative options that are currently not recommended in several guidelines, including the most recent 2022 AHA scientific statement.( 1 ) Direct oral anticoagulants demonstrate comparable efficacy to vitamin K antagonists in multiple meta-analyses, potentially offering a beneficial effect in terms of reduced bleeding complications. Ongoing randomized trials seek to elucidate this further.( 1 ) Although thrombolysis is presumed to potentially increase the risk of embolism, the absence of evidence was cited as the major rationale for not recommending surgery.( 1 ) Nonetheless, successful thrombolysis cases have been documented.( 37 ) Some advocate slow infusion low-dose thrombolysis as the most reasonable option for individuals requiring additional therapy to anticoagulation but are unsuitable for or unwilling to undergo surgery.( 38 ) While anticoagulation alone is generally effective, the risk of embolism remains at 5–20%,( 35 , 39 ) and even apparently well-organized thrombi can become more fragile and mobile. Bleeding complications occur in approximately 15% of cases.( 35 ) Predicting which patients will continue to experience embolic events despite anticoagulation is challenging, especially in those with rapid changes in ventricular function, such as Takotsubo’s syndrome( 12 , 13 ) or other transient cardiomyopathies like peripartum cardiomyopathy or viral myocarditis. Close monitoring with serial imaging to track changes in clot appearance is recommended, with early consideration of surgical intervention if necessary, particularly in patients with a high-functioning baseline for whom a stroke would be apparently devastating. Surgical thrombectomy is typically performed as a concomitant procedure during coronary artery bypass grafting or LV restoration surgery, both of which are relevant for ischemic etiologies. It can also be done as an isolated procedure in cases where there is significant concern regarding a potential catastrophic embolic event or when anticoagulation has not produced a satisfactory response. Although the AHA scientific statement recommends switching to a different class of anticoagulants as the first-line approach in cases of LV thrombus, certain morphologies of thrombus and specific patient populations may benefit optimally from surgical intervention, which is not always given due consideration. Surgeons may be hesitant to offer surgical intervention to patients at high risk of emboli due to factors such as the morbidity of surgery in patients with reduced function and technical challenges in visualizing the thrombus adequately. Surgical approaches can include sternotomy, minimally invasive right( 26 , 40 – 43 ) or left thoracotomy, or robotic-assisted surgery,( 36 , 44 ) with variations in cardiac incision techniques. Historically, these procedures often required left ventriculotomy, which could have adverse effects on LV function and lead to arrhythmias; however, alternatives such as transaortic or transmitral approaches are now available. Many reports advocate endoscope use, particularly during open sternotomy, to avoid ventriculotomy and ensure complete thrombus resection.( 45 , 46 ) While minimally invasive incisions are appealing, visualization remains challenging, and the use of long-shafted instruments may be limiting. Robotic platforms offer several advantages, notably avoiding sternotomy and ventriculotomy. They provide superior visualization with 10× magnification and a 3-dimensional image controlled by the surgeon, coupled with the robotic wrists offering full dexterity even within the left ventricle. This allows for safe and complete thrombus removal with minimal risk of injury to adjacent structures. Complete thrombus regression with anticoagulation treatment alone is associated with reduced mortality,( 35 ) potentially indicating patient-specific factors. Robotic surgery facilitates rapid and complete thrombectomy, possibly influencing survival. This study represents the largest reported investigation into robotic LV thrombectomy, encompassing patients with varying ventricular function, some with procoagulant/proinflammatory conditions, and others without obvious risk factors for LV thrombus formation. All patients underwent successful surgery without complications. The robotic approach also facilitated rapid recovery and return to rehabilitation, which is an important consideration for this patient population. After one year, all patients discontinued anticoagulation therapy. During a median follow-up period of six years with serial echocardiographic imaging, no further thrombus formation occurred. The observed improvement in LV function may have contributed to the absence of recurrence. Referral to cardiac services allowed these patients access to optimal heart failure medical treatment, which may have been overlooked if they had continued to be primarily managed by a neurologist or other physician. Despite its strengths, this study has some limitations. The small number of cases selected inevitably limits the broader applicability of our results to all patients with mobile LV thrombi. While there may be a counterargument suggesting that individuals with a history of previous cerebral emboli are at a higher risk of surgical complications, the assumption that intervening preemptively would be beneficial is speculative. Consequently, it is important to acknowledge that embolism is a common issue and should be carefully considered in the context of treatment decisions. Conclusion Our study findings revealed surgical thrombectomy as a safe and effective procedure, especially when ventriculotomy is avoided. We contend that robotic LV thrombus resection outperforms sternotomy and other minimally invasive approaches, enabling complete thrombus removal via a left atrial transmitral approach while minimizing surgical complications through enhanced visualization and dexterity, leading to improved recovery. Owing to these advantages, we advocate for surgical thrombectomy as the primary treatment for floating LV thrombi in this era of robotic surgery. Nevertheless, further research is required to explore the expanded role of surgery as an alternative to anticoagulation alone in patients without embolization and those with mobile thrombi, particularly in cases with changing morphology and rapidly improving ventricular function. Declarations Author Contribution Paul Cullen- Writing–draft, review & editingNai-Kuan Chou- review & editingLing-Yi Wei- Methodology, Validation, review & editingHsi-Yu Yu - Validation, review & editingNai-Hsin Chi- Conceptualization, investigation, methodology, data curation, formal analysis, project administration, visualization, resources (provision of patient data), writing-review, editing, and supervision. Acknowledgement The authors thank the staff at the Seventh Core Laboratory, Department of Medical Research, National Taiwan University Hospital. The manuscript English editing fee was partial supported by National Science and Technology Council (112-2314-B-002-262-). Supported by National Taiwan University Hospital (113-S0185). Financial support and sponsorship None Conflict of interest None Presentation None References Levine GN, McEvoy JW, Fang JC, Ibeh C, McCarthy CP, Misra A, et al. 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Cite Share Download PDF Status: Published Journal Publication published 24 Apr, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 29 Mar, 2025 Reviews received at journal 27 Jan, 2025 Reviewers agreed at journal 23 Jan, 2025 Reviewers invited by journal 23 Jan, 2025 Editor assigned by journal 19 Dec, 2024 Submission checks completed at journal 19 Dec, 2024 First submitted to journal 18 Dec, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5667084","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":392591459,"identity":"3a096e0a-5b3a-4322-a9ae-12ae9e9b6f23","order_by":0,"name":"Paul Cullen","email":"","orcid":"","institution":"National Taiwan University Hospital, National Taiwan University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Cullen","suffix":""},{"id":392591461,"identity":"2f8f89d3-4846-482c-acff-dc553023585c","order_by":1,"name":"Nai-Kuan Chou","email":"","orcid":"","institution":"National Taiwan University Hospital, National Taiwan University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Nai-Kuan","middleName":"","lastName":"Chou","suffix":""},{"id":392591462,"identity":"34499f6a-8e38-4ef1-8367-cdf0699066c8","order_by":2,"name":"Ling-Yi Wei","email":"","orcid":"","institution":"National Taiwan University Hospital, National Taiwan University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ling-Yi","middleName":"","lastName":"Wei","suffix":""},{"id":392591468,"identity":"380339f8-dc84-4a70-b297-d9447af6a4ae","order_by":3,"name":"Hsi-Yu Yu","email":"","orcid":"","institution":"National Taiwan University Hospital, National Taiwan University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hsi-Yu","middleName":"","lastName":"Yu","suffix":""},{"id":392591469,"identity":"99cf553e-dfc6-416b-9980-db030101fd6b","order_by":4,"name":"Nai-Hsin Chi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYDACCcYGBgaDAwxsDMwHQFwZUrSwJYC4PERoAZMgC3gMQCzCWvhnN7c9+FFwx55Puufzqxs1FjwM7IePbsBryZ2D7YY9Bs8S22TObrPOOQZ0GE9a2g18WgwkEtskeAwOJ7BJ5G4zzmEDapHgMSOoRfKPwWF7NomcZ8Y5/4jUIg20hbFNIof5cW4bEVokbgC1yBgcBjovzYw5t0+Ch42QX/hnpD+TfPPnsL38jOTHn3O+1cnxsx8+hlcLMmADxxEbscpBgPkDKapHwSgYBaNg5AAAXkdEOsG+6EYAAAAASUVORK5CYII=","orcid":"","institution":"National Taiwan University Hospital, National Taiwan University College of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Nai-Hsin","middleName":"","lastName":"Chi","suffix":""}],"badges":[],"createdAt":"2024-12-18 07:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5667084/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5667084/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-025-02341-1","type":"published","date":"2025-04-24T15:57:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":72363093,"identity":"caf9671c-874e-42c9-bbc4-f135ebb0c847","added_by":"auto","created_at":"2024-12-26 06:12:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":457323,"visible":true,"origin":"","legend":"\u003cp\u003eProcedure Overview. A. Thrombi within the left ventricular cavity are predominantly located in the apical region, typically floating within the ventriclerather than adhering to the myocardial wall. B. Utilizing a left atrial approach and robotic retractor, the left atrium was exposed. C. The retractor was then positioned to the anterior mitral leaflet, elevating it for optimal access. With the scope advanced into the left ventricle, the thrombus in the ventricle was carefully checked and completely removed.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-5667084/v1/4159cb32fa73f3a001ffab15.png"},{"id":72363092,"identity":"40d29851-e332-405b-86b6-d9d935485938","added_by":"auto","created_at":"2024-12-26 06:12:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1588688,"visible":true,"origin":"","legend":"\u003cp\u003eOperation steps. A: Robotic platform, expose left atrium through pulmonary vein to left atriaum groove, B: Elevated left atrium by atrial retractor and expose mitral valve. C: Advance atrial retractor on anterior mitral leaflet and expose left ventricle. D: The floating thrombus in the ventricle can be checked. E: Remove the organized thrombus away from trabeculation. F: Endomyocardium biopsy can also be performed using this approach to confirm thrombus etiology.\u003c/p\u003e","description":"","filename":"Fig21.png","url":"https://assets-eu.researchsquare.com/files/rs-5667084/v1/dc5aea75bf2ecc2a8102c60a.png"},{"id":72363096,"identity":"7376cc22-a2c2-46c8-90a3-183677abf415","added_by":"auto","created_at":"2024-12-26 06:12:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1086099,"visible":true,"origin":"","legend":"\u003cp\u003eA: The image of patient number 2: the yellow arrow indicates the thrombus floating in ventricular apex. The operation pictures are also provided. B: The image of patient number 4: the yellow arrow indicates the thrombus floating in ventricular apex. The operation pictures are also provided.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-5667084/v1/3a359c136f0c03687083c768.png"},{"id":81569926,"identity":"1bb9c4ca-4152-4a06-8993-ca6f83986bda","added_by":"auto","created_at":"2025-04-28 16:12:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3505327,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5667084/v1/151050e9-5616-4c86-8ddb-0c56327e8e57.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robotic transmitral resection of floating left ventricular thrombus","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe role of surgery in managing left ventricular thrombi remains controversial to date. While anticoagulation is generally preferred, alternative approaches are considered for refractory cases. Despite the American Heart Association (AHA) emphasizing the lack of evidence against the non-recommendation of surgery,(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) surgical intervention has emerged as a valuable option in cases involving mobile thrombi, especially those \u0026ldquo;floating\u0026rdquo; and adhering solely to the left ventricular (LV) trabeculae. However, in such cases, the risk of embolization is increased, particularly among individuals who have previously experienced cerebral events. Moreover, these patients often experienced functional limitations due to their condition, making surgeons hesitant to pursue traditional approaches like sternotomy and left ventriculotomy.\u003c/p\u003e \u003cp\u003eTo address these challenges, robotic techniques have been employed to access the left ventricle via the left atrium and mitral valve. Given the superior visualization and dexterity offered by robotic technology, we contend that it represents the optimal approach for surgical LV thrombectomy and may warrant broader adoption.\u003c/p\u003e \u003cp\u003eThis study aimed to present our experience with a surgical technique derived from our highly successful robotic mitral program.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Patients\u003c/h2\u003e \u003cp\u003eThis retrospective observational cohort study was conducted at our University Hospital on patients who underwent LV thrombus resection within our robotic cardiac surgery program from January 2012 to October 2023. (The study is approved by IRB 202401213RINC).\u003c/p\u003e \u003cp\u003e \u003cb\u003eSurgical Technique\u003c/b\u003e (Fig.\u0026nbsp;1, 2 )\u003c/p\u003e \u003cp\u003eAll procedures were performed using the da Vinci Si or Xi robot (Intuitive Surgical, Sunnyvale, CA, USA) and based on our extensive experience with robotic mitral valve surgery.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePatients were positioned with slight elevation of the right side, the right arm extended behind the posterior axillary line, the right leg everted, and the table rotated leftward. Anesthetic lines were placed in the right radial artery and internal jugular vein (RIJV) with a single-lumen endotracheal tube.\u003c/p\u003e \u003cp\u003eFollowing skin preparation and draping, percutaneous access to the RIJV close to the clavicle, right common femoral vein (RCFV), and right common femoral artery (RCFA) was achieved using ultrasound guidance. Pre-closure of the RCFA was performed with two PerClose Proglides (Abbott, Plymouth, MN, USA).\u003c/p\u003e \u003cp\u003eA 3 cm working port in the right 4th intercostal space (ICS) was created, and an XS Alexis (Applied Medical, Rancho Santa Margarita, CA, USA) soft-tissue retractor was inserted without a rib spreader. Subsequent ports were placed in the following sequence: right arm via the 6th ICS, left atrial (LA) retractor via the 4th ICS midway between the midclavicular line and sternal edge, camera via the 4th ICS just medial to the working port, left arm via the 3rd ICS, and a non-robotic port in the 4th ICS posteriorly for later passage of a pericardial stay suture and drop vent sucker.\u003c/p\u003e \u003cp\u003eAfter confirming hemostasis, heparin was administered, and cannulation was performed in the following order: RCFA, RCFV into the inferior vena cava (IVC), and RIJV into the superior vena cava under transesophageal echocardiography guidance after bypass initiation.\u003c/p\u003e \u003cp\u003eThe robot was docked, and the pericardium was opened anteriorly 1 cm from the sternum, extending superiorly towards the IVC and the lateral pericardial reflection of the aorta. Pericardial stays were placed at either end and removed through the posterior 4th ICS port with a tiny stab incision in the 5th ICS posteriorly to create a \u0026ldquo;platform\u0026rdquo; of the pericardium and ensure the lung was kept out of the way.\u003c/p\u003e \u003cp\u003eFollowing the pericardium opening, a long shaft cardioplegic needle was used on the aortic root, and a detachable aortic clamper (Glauber clamp, Cardio Medical GmbH, Langenhagen, Germany) was inserted through the working port into the thoracic cage. Afterward, antegrade cardioplegia (St. Thomas Hospital No. 2, HTK, and adenosine) was administered. The left atrium was opened with monopolar curved scissors, and the LA retractor was positioned to provide excellent visualization of the left ventricle and pathology (Fig.\u0026nbsp;1). This, combined with the dexterity of the robotic arms, facilitated the retrieval of the thrombus with relative ease and ensured complete resection (Fig.\u0026nbsp;2D,E). A small endomyocardial biopsy was performed over the apex to confirm the final pathological findings and assess thrombus etiology (Fig.\u0026nbsp;2F).\u003c/p\u003e \u003cp\u003eFollowing de-airing, the LA was closed in two layers using a 4-O Goretex suture, the antegrade cannula was removed, and the cannulation site was sutured. If hemostasis was deemed satisfactory, the patient was gradually weaned off the bypass during the closure of the pericardium and wounds.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection and Analysis\u003c/h3\u003e\n\u003cp\u003ePatient data were retrieved from the Robotic Cardiac Surgery Registry and the hospital's electronic medical records. Numerical data were expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and frequencies of simple events were expressed as percentages. All statistical analyses were performed using Microsoft Excel.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatient characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. We identified five consecutive patients with a median age of 46 years (range: 36\u0026ndash;63 years). Indications for surgery in all patients included \u0026ldquo;floating\u0026rdquo; LV thrombus without a significant mural attachment and a history of systemic embolization. Three patients experienced transient ischemic attacks (TIAs), one had a stroke (patient 2), and one presented with brachial artery occlusion (patient 4) (Fig.\u0026nbsp;3). It is worth mentioning that despite preoperative anticoagulant administration, thrombus persistence was observed in all patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients\u0026rsquo; characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmboli event\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePre-operation Cardiac function\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLVEF %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLVIDd (cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLVISd (cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLV thrombus (cm)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.4\u0026times;1.6\u003c/p\u003e \u003cp\u003e0.8\u0026times;0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRight temporal infarction, right side\u003c/p\u003e \u003cp\u003eweakness, resolved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.2\u0026times;1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.0\u0026times;0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRight brachial artery\u003c/p\u003e \u003cp\u003eocclusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.2\u0026times;0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.1\u0026times;0.6\u003c/p\u003e \u003cp\u003e0.5\u0026times;0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eAbbreviations: TIA, Transient ischemic attack\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAlthough none of the patients had coronary artery disease, four had reduced LV function. Complete resection was successfully achieved with a single cardiopulmonary bypass in all patients, confirmed through an intraoperative TOE.\u003c/p\u003e \u003cp\u003eNo conversions to alternative approaches or postoperative deaths, strokes, or major complications were reported.\u003c/p\u003e \u003cp\u003eAnticoagulation was initiated with subcutaneous prophylactic heparin, followed by coumadin on day 1. The mean time to achieve therapeutic anticoagulation/ international normalized ratio (INR) was 3 days, reaching the targeted INR of 2\u0026ndash;3 by day 5. Postoperatively, anticoagulation was continued for two years in the first patient and for one year in the remaining patients.\u003c/p\u003e \u003cp\u003eHistopathological examinations of LV biopsies taken intraoperatively revealed dilated cardiomyopathy in three patients, while no specific abnormalities were identified in the remaining two.\u003c/p\u003e \u003cp\u003ePostoperative medications included anticoagulation and goal-directed medical therapy for heart failure, if necessary. Notably, LV function improved in all patients during follow-up. All patients remained alive without LV thrombus recurrence or further embolic events during a median follow-up of 6 years (range: 4\u0026ndash;9 years), with no bleeding complications reported (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-surgery outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-surgery cardiac function\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLVEF %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLVIDd (cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLVISd (cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThrombus in LV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePathology findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAnticoagulation\u003c/p\u003e \u003cp\u003eduration\u003c/p\u003e \u003cp\u003eyear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFollow up time\u003c/p\u003e \u003cp\u003eyear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEmboli events after surgery\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCompatible with DCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCompatible with DCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo specific finding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo specific finding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCompatible with DCM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eLVEF: left ventricular ejection fraction, LVIDd: left ventricular internal diameter in diastolic phase, LVISd: left ventricular internal diameter in systolic phase, LV: left ventricle, DCM: dilated cardiomyopathy.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLV thrombus poses a significant risk of embolization, observed in up to 22% of cases,(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) resulting in various complications such as coronary,(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) cerebrovascular, renal, bowel, splenic, or lower-limb ischemia, or even complete aortic occlusion.(\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) This condition carries a high mortality rate, with over 10% of patients dying within one year of diagnosis(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHistorically, myocardial infarction was the primary cause, resulting in hypokinetic, akinetic, or dyskinetic aneurysmal segments, most frequently affecting the apex. However, with the advent of rapid coronary angiography and stenting, the incidence following ST-elevation myocardial infarction (STEMI) treatment via percutaneous coronary intervention (PCI) has reduced to 1.6%.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Uncommon etiologies, such as blunt trauma-induced left anterior descending (LAD) injuries, have also been reported.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eNon-ischemic causes of heart failure can also lead to LV thrombus, including Takotsubo syndrome,(\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) peripartum cardiomyopathy,(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) hypertrophic cardiomyopathy,(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) sarcoidosis,(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Churg-Strauss syndrome,(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) anabolic steroid use,(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) LV non-compaction,(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) pediatric myocarditis,(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and multisystem inflammatory syndrome in children (MIS-C) associated with Covid-19.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) Specifically, the reported incidence of LV thrombosis in dilated cardiomyopathy varies widely, ranging from 2\u0026ndash;36%.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAdditionally, LV thrombus can also occur in patients with normal ventricular function, as observed in one of our cases.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) However, while procoagulant or proinflammatory conditions such as thrombophilia,(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) hypereosinophilia,(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) antiphospholipid syndrome,(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) human immunodeficiency (HIV) disease,(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) Crohn\u0026rsquo;s disease,(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and ulcerative colitis(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) are frequently implicated, the etiology remains unknown in some cases. Moreover, research has suggested severe dehydration as a potential contributing factor.(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eLV thrombus can complicate valvular pathology, such as aortic stenosis, regardless of normal(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and abnormal(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) ventricular function. Dense mitral annular calcification can also be associated with thrombus formation along the mitral annulus, even in the presence of normal ventricular and valvular function.(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) Additional risk factors include malignancies and chronic renal failure.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWhile symptomatic embolization is a common presentation, fever may be the only symptom,(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) or a thrombus may be incidentally discovered during cardiac imaging.\u003c/p\u003e \u003cp\u003eTo detect apical thrombus, contrast-enhanced echocardiography is preferred over standard transthoracic echocardiography, and transesophageal echocardiography does not provide additional sensitivity.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Despite cardiac MRI being more sensitive and specific than other modalities, it is obviously less convenient; therefore, contrast-enhanced transthoracic echocardiography appears to be the best choice.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Thus, subsequent imaging should ideally be performed with a test that is at least as sensitive as the initial diagnostic study(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The primary treatment for confirmed LV thrombus is anticoagulation, with thrombolysis and surgical thrombectomy being alternative options that are currently not recommended in several guidelines, including the most recent 2022 AHA scientific statement.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Direct oral anticoagulants demonstrate comparable efficacy to vitamin K antagonists in multiple meta-analyses, potentially offering a beneficial effect in terms of reduced bleeding complications. Ongoing randomized trials seek to elucidate this further.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAlthough thrombolysis is presumed to potentially increase the risk of embolism, the absence of evidence was cited as the major rationale for not recommending surgery.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Nonetheless, successful thrombolysis cases have been documented.(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Some advocate slow infusion low-dose thrombolysis as the most reasonable option for individuals requiring additional therapy to anticoagulation but are unsuitable for or unwilling to undergo surgery.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWhile anticoagulation alone is generally effective, the risk of embolism remains at 5\u0026ndash;20%,(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) and even apparently well-organized thrombi can become more fragile and mobile. Bleeding complications occur in approximately 15% of cases.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Predicting which patients will continue to experience embolic events despite anticoagulation is challenging, especially in those with rapid changes in ventricular function, such as Takotsubo\u0026rsquo;s syndrome(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) or other transient cardiomyopathies like peripartum cardiomyopathy or viral myocarditis. Close monitoring with serial imaging to track changes in clot appearance is recommended, with early consideration of surgical intervention if necessary, particularly in patients with a high-functioning baseline for whom a stroke would be apparently devastating.\u003c/p\u003e \u003cp\u003eSurgical thrombectomy is typically performed as a concomitant procedure during coronary artery bypass grafting or LV restoration surgery, both of which are relevant for ischemic etiologies. It can also be done as an isolated procedure in cases where there is significant concern regarding a potential catastrophic embolic event or when anticoagulation has not produced a satisfactory response.\u003c/p\u003e \u003cp\u003eAlthough the AHA scientific statement recommends switching to a different class of anticoagulants as the first-line approach in cases of LV thrombus, certain morphologies of thrombus and specific patient populations may benefit optimally from surgical intervention, which is not always given due consideration.\u003c/p\u003e \u003cp\u003eSurgeons may be hesitant to offer surgical intervention to patients at high risk of emboli due to factors such as the morbidity of surgery in patients with reduced function and technical challenges in visualizing the thrombus adequately. Surgical approaches can include sternotomy, minimally invasive right(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR41 CR42\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) or left thoracotomy, or robotic-assisted surgery,(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) with variations in cardiac incision techniques. Historically, these procedures often required left ventriculotomy, which could have adverse effects on LV function and lead to arrhythmias; however, alternatives such as transaortic or transmitral approaches are now available.\u003c/p\u003e \u003cp\u003eMany reports advocate endoscope use, particularly during open sternotomy, to avoid ventriculotomy and ensure complete thrombus resection.(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) While minimally invasive incisions are appealing, visualization remains challenging, and the use of long-shafted instruments may be limiting.\u003c/p\u003e \u003cp\u003eRobotic platforms offer several advantages, notably avoiding sternotomy and ventriculotomy. They provide superior visualization with 10\u0026times; magnification and a 3-dimensional image controlled by the surgeon, coupled with the robotic wrists offering full dexterity even within the left ventricle. This allows for safe and complete thrombus removal with minimal risk of injury to adjacent structures.\u003c/p\u003e \u003cp\u003eComplete thrombus regression with anticoagulation treatment alone is associated with reduced mortality,(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) potentially indicating patient-specific factors. Robotic surgery facilitates rapid and complete thrombectomy, possibly influencing survival.\u003c/p\u003e \u003cp\u003eThis study represents the largest reported investigation into robotic LV thrombectomy, encompassing patients with varying ventricular function, some with procoagulant/proinflammatory conditions, and others without obvious risk factors for LV thrombus formation. All patients underwent successful surgery without complications. The robotic approach also facilitated rapid recovery and return to rehabilitation, which is an important consideration for this patient population.\u003c/p\u003e \u003cp\u003eAfter one year, all patients discontinued anticoagulation therapy. During a median follow-up period of six years with serial echocardiographic imaging, no further thrombus formation occurred. The observed improvement in LV function may have contributed to the absence of recurrence. Referral to cardiac services allowed these patients access to optimal heart failure medical treatment, which may have been overlooked if they had continued to be primarily managed by a neurologist or other physician.\u003c/p\u003e \u003cp\u003eDespite its strengths, this study has some limitations. The small number of cases selected inevitably limits the broader applicability of our results to all patients with mobile LV thrombi. While there may be a counterargument suggesting that individuals with a history of previous cerebral emboli are at a higher risk of surgical complications, the assumption that intervening preemptively would be beneficial is speculative. Consequently, it is important to acknowledge that embolism is a common issue and should be carefully considered in the context of treatment decisions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study findings revealed surgical thrombectomy as a safe and effective procedure, especially when ventriculotomy is avoided. We contend that robotic LV thrombus resection outperforms sternotomy and other minimally invasive approaches, enabling complete thrombus removal via a left atrial transmitral approach while minimizing surgical complications through enhanced visualization and dexterity, leading to improved recovery.\u003c/p\u003e \u003cp\u003eOwing to these advantages, we advocate for surgical thrombectomy as the primary treatment for floating LV thrombi in this era of robotic surgery. Nevertheless, further research is required to explore the expanded role of surgery as an alternative to anticoagulation alone in patients without embolization and those with mobile thrombi, particularly in cases with changing morphology and rapidly improving ventricular function.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003ePaul Cullen- Writing\u0026ndash;draft, review \u0026amp; editingNai-Kuan Chou- review \u0026amp; editingLing-Yi Wei- Methodology, Validation, review \u0026amp; editingHsi-Yu Yu - Validation, review \u0026amp; editingNai-Hsin Chi- Conceptualization, investigation, methodology, data curation, formal analysis, project administration, visualization, resources (provision of patient data), writing-review, editing, and supervision.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank the staff at the Seventh Core Laboratory, Department of Medical Research, National Taiwan University Hospital. The manuscript English editing fee was partial supported by National Science and Technology Council (112-2314-B-002-262-). Supported by National Taiwan University Hospital (113-S0185).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFinancial support and sponsorship\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePresentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLevine GN, McEvoy JW, Fang JC, Ibeh C, McCarthy CP, Misra A, et al. Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association. Circulation. 2022;146(15):e205-e23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChou NK, Wang YC, Huang CH, Chi NH. 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Journal of cardiothoracic surgery. 2017;12(1):41.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Robotic left ventricular thrombectomy, Floating thrombi, Robotic transmitral approach, Left ventricular thrombectomy, Surgical thrombectomy","lastPublishedDoi":"10.21203/rs.3.rs-5667084/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5667084/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite the role of surgery in the management of left ventricular (LV) thrombi remaining controversial, robotic LV thrombectomy has emerged as a viable treatment option. This study aimed to present our successful experience with a robotic mitral program, detailing the operative technique.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective analysis of our institutional database to identify patients who underwent LV thrombectomy using the da Vinci robot system. Subsequently, serial echocardiograms and short- and long-term outcomes were reviewed and analyzed using descriptive statistics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of five patients (median age: 46 years) were included in this study. All patients presented with a floating LV thrombus and a history of embolization. Among them, four patients experienced reduced heart function, none had coronary artery disease, three experienced dilated cardiomyopathy. Complete resection was achieved in all cases, with no postoperative deaths, strokes, or major complications. Additionally, LV function showed improvement during follow-up periods. Postoperative anticoagulation was continued for two years in one patient and one year in the remaining patients. No recurrence or further embolic events were observed during the median follow-up period of 6 years.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eRobotic LV thrombectomy yields excellent outcomes and should be considered early for patients with floating LV thrombi. However, further investigation is warranted to determine the optimal timing of this intervention and its role in the treatment paradigm, including whether these results can be extrapolated to patients with other forms of mobile thrombus and/or to support surgery as the primary prevention of systemic embolization.\u003c/p\u003e","manuscriptTitle":"Robotic transmitral resection of floating left ventricular thrombus","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-26 06:12:11","doi":"10.21203/rs.3.rs-5667084/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-29T19:37:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-27T05:17:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47092371624928416619011471000119324205","date":"2025-01-23T18:29:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-23T07:53:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-12-20T00:30:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-12-19T12:15:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2024-12-18T07:30:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9e45dc4f-b3b6-4bf5-a8f3-f689c9c26ff1","owner":[],"postedDate":"December 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-28T16:07:53+00:00","versionOfRecord":{"articleIdentity":"rs-5667084","link":"https://doi.org/10.1007/s11701-025-02341-1","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2025-04-24 15:57:14","publishedOnDateReadable":"April 24th, 2025"},"versionCreatedAt":"2024-12-26 06:12:11","video":"","vorDoi":"10.1007/s11701-025-02341-1","vorDoiUrl":"https://doi.org/10.1007/s11701-025-02341-1","workflowStages":[]},"version":"v1","identity":"rs-5667084","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5667084","identity":"rs-5667084","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}