Video-assisted cardioscopy in a patient with left ventricular tumor of unknown etiology
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《血管的通路杂志》
1 Department of Cardiothoracic Surgery, Southwest Cardiothoracic Centre, Plymouth, PL6 8DH, UK
2 Department of Cardiology, Southwest Cardiothoracic Centre, Plymouth, PL6 8DH, UK
Abstract
Ventricular tumors are a rare clinical entity with limited posibilities for excision diagnosis. For benign conditions surgical excision is the treatment of choice. A case presenting as a clinical conundrum with left ventricular tumor and complex past medical history is discussed. Aortic transvalvular video-assisted cardioscopy was used for removal and definitive diagnosis.
Key Words: Left ventricular tumor; Videocardioscopy; Video-assisted cardiac surgery
1. Introduction
Intracardiac tumors are a rare clinical entity on which the mainstay of diagnosis relies on clinical history and imaging techniques. Malignant tumors very rarely justify surgical intervention and minimally invasive approaches are required in cases of uncertain diagnosis. The use of the videoscope via an aortic transvalvular approach appears ideally suited under these circumstances.
2. Case report
A 60-year-old male was admitted to a medical ward presenting with signs and symptoms of severe left ventricular failure. His chest X-ray on admission confirmed pulmonary oedema. ECG showed a known right bundle branch block. Trans thoracic echocardiography showed a pedunculated large left ventricular mass 2.0x2.5 cm, originating from the free wall of the left ventricle, with globally impaired left ventricular function. Transoesophageal echo confirmed the mass in the left ventricle and suggested a further mass in the apex of the right ventricle of approximately 2 cm in diameter. Computed tomography and magnetic resonance imaging demonstrated both masses with no further abnormalities (Fig. 1 a,b). Four months previously he was admitted on a surgical ward with an episode of acute right lower limb ischaemia which was treated conservatively. Five years previously he had been treated for acute promyelocytic leukaemia with chemotherapy within the AML 12 Protocol, including Anthracycline. A Hickman Line was inserted at that time without complications. During this time he developed severe fungal chest infection with multiple pulmonary irregular cavitating nodules visualised on CT Scan. Due to his past medical history the possibility of a primary malignant cardiac tumor was raised and could not be excluded with the findings made on the diagnostic imaging. As the prognosis for malignant cardiac tumors is uniformly reported to be poor the patient was anticoagulated and reviewed 3 months later. At this stage a repeat transoesophageal echocardiogram showed no change in the left ventricular mass and the mass in the right ventricle was no longer visualised. Embolisation of the right ventricular mass was assumed to have occurred indicating the likely diagnosis of an intracavitary thrombus. This justified surgical intervention in order to prevent further complications from potential embolisation of the left ventricular mass and to obtain definite tissue diagnosis.
Median sternotomy was performed. Full heparinization cardiopulmonary bypass between a two-stage right atrial venous cannula and a 24-aortic return cannula was performed. The patient was cooled to 34 °C. Myocardial protection established with single shot anterograde cold blood cardioplegia via the aortic root. Access to the intracavitary tumor was achieved via a transverse aortotomy (Fig. 2a), thus avoiding the far more invasive approach via a ventriculotomy with its potential complications. A 10 mm 0 ° Storz rigid thoracocscope was introduced through the aortic valve to visualise the cavity of the left ventricle. VATS instruments were used for exploration although they proved to be rather long in this situation. A 3x2 cm mass with a thin stalk attached to a trabeculum of the free wall was identified and transifixed facilitating the approximation of the mass close to the aortic valve (Fig. 2b). The mass was excised and a sample was sent for frozen section revealing no malignancy. The remainder of the left ventricular cavity was re-explored and no further lesion was identified. His postoperative recovery was uneventful. Pathological examination revealed a calcified thrombus. Microbiology was negative.
3. Discussion
Primary cardiac tumors are a rare clincal entity. The differential diagnosis includes thrombus, myxoma, lymphoma and sarcoma. The past medical history of this patient raised the possibility of the spread of lymphoma. No association between the chemotherapy received and primary cardiac tumors could be found in the literature. Only 25% of primary cardiac tumors are reported to be malignant. In a large postmortem series the overall incidence varies between 0.0017 and 0.03% [1]. Diagnosis relies on clinical history and imaging techniques and can be misleading [2]. Very rarely tissue diagnosis may be obtained by cardiac catheterisation. Survival rates for malignant cardiac tumors are unifomly poor regardless of treatment strategies which may include major surgery [3]. On the other hand the documented poor ventricular function of this patient could explain an increased risk of intraventricular thrombus formation. Severely impaired ventricular function due to cardiotoxicity of Anthracycline requiring cardiac transplant has been described [4]. A histologically confirmed diagnosis was therefore crucial for surgical decision making.
The use of video assisted cardioscopy has recently reported to be very useful in situations where minimally invasive approaches are required without compromising the quality of the intervention. This seems to be particularly useful in cases with uncertain diagnosis where the risks of a more invasive approach, such as ventriculotomy, might outweigh the possible benefits [5]. Patients with already impaired ventricular function may especially benefit from this approach. Video assisted cardioscopy has previously been used for a variety of cardiac surgical procedures including removal of primary left ventricular myxoma [6] and removal of left ventricular thrombus [7] where the benefits of this approach have been well described (for review see Reuthenbach et al. [8]). Further developments of this technique could include the use of a limited upper sternotomy as described for minimally invasive aortic valve replacement [9] and in effect no publication using this technique in conjuction with video assisted cardioscopy has been published to our knowledge. However, the authors experience in this approach was limited therefore precluding consideration of this potential route.
In conclusion this case report highlights the difficulties of reconciliating the need of obtaining tissue diagnosis for appropriate decision making with the magnitude and potential complications of the diagnostic procedure itself. This is especially relevant in cases of potential malignant disease with limited prognosis. Further development of this technique will be dependent on centres with relevant expertise in this field.
Acknowledgements
The authors would like to acknowledge Dr M.D. Hamon and Dr A. Prentice, Consultant Haematologists, for reviewing this paper.
References
Poole GV Jr., Meredith JW, Breyer RH, Mills SA. Surgical Implications in Malignant Cardiac Disease. Ann Thorac Surg 1983;36:484–491.
Hasegawa T, Nakagawa S, Chino M, Kunihiro T, Ui S, Kimura M. Primary Cardiac Sarcoma Mimicking Benign Myxoma: a Case Report. J Cardiol 2002;39:321–325.
Murphy MC, Sweeney MS, Putnam JB Jr, Walker WE, Frazier OH, Ott DA, Cooley DA. Surgical Treatment of Cardiac Tumors: a 25-Year Experience. Ann Thorac Surg 1990;49:612–617.
Thomas X, Le QH, Fiere D. Anthracycline-Related Toxicity Requiring Cardiac Transplantation in Long-Term Disease-Free Survivors With Acute Promyelocytic Leukemia. Ann Hematol 2002;81:504–507.
Bauer EP, Reuthebuch OT, Roth M, Klovekorn WP. Diagnostic Transaortic Cardioscopy of the Left Ventricle. Ann Thorac Surg 1996;62:1845–1846.
Greco E, Mestres CA, Cartana R, Pomar JL. Video-Assisted Cardioscopy for Removal of Primary Left Ventricular Myxoma. Eur J Cardiothorac Surg 1999;16:677–678.
Mazza IL, Jacobs JP, Aldousany A, Chang AC, Burke RP. Video-Assisted Cardioscopy for Left Ventricular Thrombectomy in a Child. Ann Thorac Surg 1998;66:248–250.
Reuthebuch O, Roth M, Skwara W, Klovekorn WP, Bauer EP. Cardioscopy: Potential Applications and Benefit in Cardiac Surgery. Eur J Cardiothorac Surg 1999;15:824–829.
Masiello P, Coscioni E, Panza A, Triumbari F, Preziosi G, Di BG. Surgical Results of Aortic Valve Replacement Via Partial Upper Sternotomy: Comparison With Median Sternotomy. Cardiovasc Surg 2002;10:333–338.(Manfred Junemann-Ramirez,)
2 Department of Cardiology, Southwest Cardiothoracic Centre, Plymouth, PL6 8DH, UK
Abstract
Ventricular tumors are a rare clinical entity with limited posibilities for excision diagnosis. For benign conditions surgical excision is the treatment of choice. A case presenting as a clinical conundrum with left ventricular tumor and complex past medical history is discussed. Aortic transvalvular video-assisted cardioscopy was used for removal and definitive diagnosis.
Key Words: Left ventricular tumor; Videocardioscopy; Video-assisted cardiac surgery
1. Introduction
Intracardiac tumors are a rare clinical entity on which the mainstay of diagnosis relies on clinical history and imaging techniques. Malignant tumors very rarely justify surgical intervention and minimally invasive approaches are required in cases of uncertain diagnosis. The use of the videoscope via an aortic transvalvular approach appears ideally suited under these circumstances.
2. Case report
A 60-year-old male was admitted to a medical ward presenting with signs and symptoms of severe left ventricular failure. His chest X-ray on admission confirmed pulmonary oedema. ECG showed a known right bundle branch block. Trans thoracic echocardiography showed a pedunculated large left ventricular mass 2.0x2.5 cm, originating from the free wall of the left ventricle, with globally impaired left ventricular function. Transoesophageal echo confirmed the mass in the left ventricle and suggested a further mass in the apex of the right ventricle of approximately 2 cm in diameter. Computed tomography and magnetic resonance imaging demonstrated both masses with no further abnormalities (Fig. 1 a,b). Four months previously he was admitted on a surgical ward with an episode of acute right lower limb ischaemia which was treated conservatively. Five years previously he had been treated for acute promyelocytic leukaemia with chemotherapy within the AML 12 Protocol, including Anthracycline. A Hickman Line was inserted at that time without complications. During this time he developed severe fungal chest infection with multiple pulmonary irregular cavitating nodules visualised on CT Scan. Due to his past medical history the possibility of a primary malignant cardiac tumor was raised and could not be excluded with the findings made on the diagnostic imaging. As the prognosis for malignant cardiac tumors is uniformly reported to be poor the patient was anticoagulated and reviewed 3 months later. At this stage a repeat transoesophageal echocardiogram showed no change in the left ventricular mass and the mass in the right ventricle was no longer visualised. Embolisation of the right ventricular mass was assumed to have occurred indicating the likely diagnosis of an intracavitary thrombus. This justified surgical intervention in order to prevent further complications from potential embolisation of the left ventricular mass and to obtain definite tissue diagnosis.
Median sternotomy was performed. Full heparinization cardiopulmonary bypass between a two-stage right atrial venous cannula and a 24-aortic return cannula was performed. The patient was cooled to 34 °C. Myocardial protection established with single shot anterograde cold blood cardioplegia via the aortic root. Access to the intracavitary tumor was achieved via a transverse aortotomy (Fig. 2a), thus avoiding the far more invasive approach via a ventriculotomy with its potential complications. A 10 mm 0 ° Storz rigid thoracocscope was introduced through the aortic valve to visualise the cavity of the left ventricle. VATS instruments were used for exploration although they proved to be rather long in this situation. A 3x2 cm mass with a thin stalk attached to a trabeculum of the free wall was identified and transifixed facilitating the approximation of the mass close to the aortic valve (Fig. 2b). The mass was excised and a sample was sent for frozen section revealing no malignancy. The remainder of the left ventricular cavity was re-explored and no further lesion was identified. His postoperative recovery was uneventful. Pathological examination revealed a calcified thrombus. Microbiology was negative.
3. Discussion
Primary cardiac tumors are a rare clincal entity. The differential diagnosis includes thrombus, myxoma, lymphoma and sarcoma. The past medical history of this patient raised the possibility of the spread of lymphoma. No association between the chemotherapy received and primary cardiac tumors could be found in the literature. Only 25% of primary cardiac tumors are reported to be malignant. In a large postmortem series the overall incidence varies between 0.0017 and 0.03% [1]. Diagnosis relies on clinical history and imaging techniques and can be misleading [2]. Very rarely tissue diagnosis may be obtained by cardiac catheterisation. Survival rates for malignant cardiac tumors are unifomly poor regardless of treatment strategies which may include major surgery [3]. On the other hand the documented poor ventricular function of this patient could explain an increased risk of intraventricular thrombus formation. Severely impaired ventricular function due to cardiotoxicity of Anthracycline requiring cardiac transplant has been described [4]. A histologically confirmed diagnosis was therefore crucial for surgical decision making.
The use of video assisted cardioscopy has recently reported to be very useful in situations where minimally invasive approaches are required without compromising the quality of the intervention. This seems to be particularly useful in cases with uncertain diagnosis where the risks of a more invasive approach, such as ventriculotomy, might outweigh the possible benefits [5]. Patients with already impaired ventricular function may especially benefit from this approach. Video assisted cardioscopy has previously been used for a variety of cardiac surgical procedures including removal of primary left ventricular myxoma [6] and removal of left ventricular thrombus [7] where the benefits of this approach have been well described (for review see Reuthenbach et al. [8]). Further developments of this technique could include the use of a limited upper sternotomy as described for minimally invasive aortic valve replacement [9] and in effect no publication using this technique in conjuction with video assisted cardioscopy has been published to our knowledge. However, the authors experience in this approach was limited therefore precluding consideration of this potential route.
In conclusion this case report highlights the difficulties of reconciliating the need of obtaining tissue diagnosis for appropriate decision making with the magnitude and potential complications of the diagnostic procedure itself. This is especially relevant in cases of potential malignant disease with limited prognosis. Further development of this technique will be dependent on centres with relevant expertise in this field.
Acknowledgements
The authors would like to acknowledge Dr M.D. Hamon and Dr A. Prentice, Consultant Haematologists, for reviewing this paper.
References
Poole GV Jr., Meredith JW, Breyer RH, Mills SA. Surgical Implications in Malignant Cardiac Disease. Ann Thorac Surg 1983;36:484–491.
Hasegawa T, Nakagawa S, Chino M, Kunihiro T, Ui S, Kimura M. Primary Cardiac Sarcoma Mimicking Benign Myxoma: a Case Report. J Cardiol 2002;39:321–325.
Murphy MC, Sweeney MS, Putnam JB Jr, Walker WE, Frazier OH, Ott DA, Cooley DA. Surgical Treatment of Cardiac Tumors: a 25-Year Experience. Ann Thorac Surg 1990;49:612–617.
Thomas X, Le QH, Fiere D. Anthracycline-Related Toxicity Requiring Cardiac Transplantation in Long-Term Disease-Free Survivors With Acute Promyelocytic Leukemia. Ann Hematol 2002;81:504–507.
Bauer EP, Reuthebuch OT, Roth M, Klovekorn WP. Diagnostic Transaortic Cardioscopy of the Left Ventricle. Ann Thorac Surg 1996;62:1845–1846.
Greco E, Mestres CA, Cartana R, Pomar JL. Video-Assisted Cardioscopy for Removal of Primary Left Ventricular Myxoma. Eur J Cardiothorac Surg 1999;16:677–678.
Mazza IL, Jacobs JP, Aldousany A, Chang AC, Burke RP. Video-Assisted Cardioscopy for Left Ventricular Thrombectomy in a Child. Ann Thorac Surg 1998;66:248–250.
Reuthebuch O, Roth M, Skwara W, Klovekorn WP, Bauer EP. Cardioscopy: Potential Applications and Benefit in Cardiac Surgery. Eur J Cardiothorac Surg 1999;15:824–829.
Masiello P, Coscioni E, Panza A, Triumbari F, Preziosi G, Di BG. Surgical Results of Aortic Valve Replacement Via Partial Upper Sternotomy: Comparison With Median Sternotomy. Cardiovasc Surg 2002;10:333–338.(Manfred Junemann-Ramirez,)