Biventricular thrombosis and survival after two different me
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A 25‐year‐old man presents to the emergency department with 12 hours of precordial discomfort and dyspnea. His vital signs were 132/76 mm Hg of blood pressure, 98 beats per minute of heart rate, 28 cycles per minute of respiratory rate, and no fever was found. The electrocardiogram showed nonspecific ST segment abnormalities and the troponin assay value was elevated. Initially a non‐ST elevation of myocardial infarction was diagnosed, and the patient received aspirin, ticagrelor, and intravenous heparin. Although the patient presented a severe angina‐like persistent chest pain, a computed tomography scan (CT‐Scan) of the thorax was performed.

The scan revealed an aortic emergency that was not suspected initially based on clinical presentation. The CT‐Scan showed a large ascending aortic aneurysm of 12.8 cm originating from the aortic valve up to 7.5 cm before the brachio‐cephalic trunk associated with right coronary artery compression. An echocardiogram also showed a severe aortic regurgitation. The patient was transferred to a tertiary cardiac surgery center. A preoperative transesophageal echocardiogram (TEE) confirmed the diagnosis of bicuspid aortic valve, aortic aneurysm with severe regurgitation, a left ventricular ejection fraction of 20%, and a doubt on the presence of an intimal flap and he underwent a Bentall procedure.

This procedure consists of the replacement of the aortic valve, aortic root, and ascending aorta by a mechanical valve conduit with the reimplantation of the coronaries. During the surgery, massive surgical bleeding required massive transfusion. The patient remained in cardiogenic shock and could not have been weaned off cardiopulmonary bypass. A peripheral veno‐arterial extra‐corporeal membrane oxygenation system (VA‐ECMO) was inserted because of the refractory shock and the patient was transferred to the intensive care unit with active bleeding, no heparin infusion, and continuous veno‐veno hemofiltration.

Six hours later, the patient was explored for surgical hemostasis. Heparin infusion was started 4 hours later, once mediastinal bleeding was minimal. Two hours later, a TEE showed large biventricular thrombi and a mechanical aortic valve prosthesis thrombosis with extension in the ascending aorta prosthesis. He was then transferred to a heart transplant center. A normal head CT‐Scan encouraged further aggressive care, even though the patient has multiorgan failure. Three days later, a total artificial heart was inserted following total heart explantation and great vessels thrombectomy was performed.