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A 71 year old white man with a history of ischaemic heart disease with severe three vessel coronary artery disease and congestive heart failure (left ventricular ejection fraction < 30%) was scheduled for coronary artery bypass grafting using warm blood cardioplegia. Routine perioperative transoesophageal echocardiography after weaning off cardiopulmonary bypass uncovered an impending intracardiac thrombus, first caught in the subvalvar apparatus of the posterior mitral valve leaflet, later presenting as a free floating left ventricular mass (LVOT, left ventricular outflow tract; EMB, intracardiac thrombus).
The oval structure, not seen at preoperative transthoracic or transoesophageal echocardiography, rapidly disappeared in the blood flow before extracorporeal circulation could be reinstituted. Further echocardiographic evaluation failed to localise the thrombus in a cardiac chamber or in the aorta. An extensive search for systemic embolisation into the peripheral arterial circulation was performed. No anisocoria was noted but a postoperative continuous Doppler flow analysis of the lower limbs revealed a possible embolism to the left tibial artery, threatening the viability of the extremity. Fortunately, distal flow in the left lower limb was successfully restored after embolectomy using a Fogarthy catheter. The patient made an uneventful recovery and was left with no long term sequelae.