Surgical Approach to a Left Ventricular Mass Guided by Transesophageal Echocardiography

A 42-yr-old man with a history of familial cardiomyopathy presented for resection of a left ventricular (LV) mass of unknown etiology. As part of his cardiomyopathy management, the patient received screening transthoracic echocardiograms (TTE) every 6–12 mo. His previous examinations were notable for a globally depressed LV ejection fraction in the 25%–30% range, with a dilated LV chamber. Eight months before surgery, TTE revealed a new 1 3 1 cm well-defined mass within the left ventricle, attached to the distal lateral wall. This was interpreted as likely representing a thrombus. Repeat TTE 1 mo before resection showed that the mass had increased in size to 1.9 3 1.5 cm and that it was now mobile and centrally echolucent. Because of the increase in the size and mobility of the mass, risk of embolism, and concern for malignancy, the patient was scheduled for surgical resection via median sternotomy. The cardiac surgeon requested transesophageal echocardiographic (TEE) guidance for best access to the mass via either a transmitral or a transaortic approach. Intraoperative two-dimensional TEE confirmed the presence of a distinct globular pedunculated mass with a cystic appearance measuring approximately 2 cm and inserting near the junction of