Malignant thymoma invading the right atrium: a rare echocardiographic finding

Malignant thymoma is a rare tumor. We report a case of malignant thymoma with intracaval extension and direct invasion of the right atrium presenting as superior vena cava syndrome.     

Hepatocellular carcinoma with inferior vena cava and right atrial tumor thrombus: A case report

This is a case report of a 45‐year‐old patient admitted with the symptom of bilateral leg swelling. Ultrasonography revealed a hyperechoic mass in the right lobe of the liver, which invaded the right hepatic vein (RHV) and extended into the inferior vena cava (IVC) and right atrium (RA). Based on the high alpha‐fetoprotein (AFP) level and the ultrasonography findings, the patient was diagnosed as having hepatocellular carcinoma (HCC) with a RHV, IVC, and RA tumor thrombus and secondary Budd–Chiari syndrome (BCS). HCC with a tumor thrombus extending into the IVC and RA has rarely been observed, and as a cause of secondary BCS, this type of HCC has been even more rarely reported.     

Severe vaginal bleeding due to vaginal metastasis from renal cell carcinoma with inferior vena cava tumor thrombus: A case report

Rationale:Renal cell carcinoma (RCC) is the most common type of kidney cancer and is the second most common urologic neoplasm. Vaginal metastasis from RCC is extremely rare clinically.Patient concerns:A 56-year-old woman presented with intermittent vaginal bleeding that had persisted for 1 month. Enhanced computed tomography examination suggested a vaginal mass (3 × 2 × 2 cm), right kidney tumor (15 × 12 × 10 cm), and an inferior vena cava tumor thrombus. During gynecologic examination, the mass was necrotic and caused uncontrollable vaginal bleeding.Diagnoses:Based on clinical and imaging examinations and the pathology, she was diagnosed as vaginal metastasis from RCC.Interventions:The patient received percutaneous transcatheter arterial embolization to stop uncontrollable vaginal bleeding, and then treated with targeted therapy.Outcomes:Vaginal bleeding disappeared after interventional embotherapy. However, disease progressed, and the patient died 9 months later.Lessons:In cases of vaginal bleeding, the possibility of metastatic renal cell carcinoma should be considered. Percutaneous transcatheter arterial embolization is an effective and novel treatment for uncontrollable vaginal bleeding caused by vaginal metastasis of RCC.     

The Role of Myocardial Contrast Echocardiography to Assess the Origin of a Mass in Right Cardiac Cavities

We report the case of a patient with hepatocellular carcinoma who was admitted to our hospital with fatigue and edema of lower extremities. Transthoracic echocardiographic examination revealed a mobile echogenic cavoatrial mass that infiltrated the inferior vena cava and extended along the vessel protruding into the right cardiac cavities. The differential diagnosis included a tumor mass originating from the liver and subsequently infiltrating the inferior vena cava and extending into the right cardiac cavities or a large thrombus formed on the tumor mass that infiltrated the inferior vena cava.     

Leiomyosarcoma of the Right Atrium Masked by a Covering Thrombus: Conflicting Results of Echocardiography and Transvenous Biopsy—In Favor of Echocardiography

A 62-year-old woman was admitted for the evaluation of pedal edema and ascitis. Echocardiography revealed a right atrial (RA) mass invading the interatrial septum and extending into the inferior vena cava (IVC). Contrast enhanced computerized tomography scan excluded extravascular involvement. An organized thrombus was diagnosed by transvenous endomyocardial biopsy. The patient was treated with continuous intravenous heparin, and died soon after from hepatic failure. Postmortem histologic examination revealed a leiomyosarcoma surrounded by a thrombus involving RA, IVC, and hepatic veins. Endomyocardial biopsy played a misleading role that affected patient's management.     

Renal adenocarcinoma with intramyopericardial and right atrial metastasis, latter via coronary sinus: report of a case

Primary renal tumors with intracardiac metastasis are not infrequent. Most of the secondary spread is blood-borne and occurs via inferior vena cava. Patients with such a spread often present with cardiac symptoms. We presume that a metastatic spread in the right atrium through coronary sinus has never been reported in the literature according to the result of a Medline search at the time of writing this report.     

Evidence for biventricular involvement in acromegaly: a Doppler echocardiographic study

To investigate left and right ventricular involvement in acromegaly,20 patients were studied by Doppler echocardiography. Nine ofthem had systemic hypertension. Right ventricular free wallthickness was significantly increased in acromegalic patients(8 ± 2 vs 4 ± 1 mm; P <0.001). Left ventricularmass index was augmented both in the whole group and in thesubgroup of normotensive acromegalics, as compared with normals(134 ± 33 and 115 ± 20 vs 80 ± 18 g.m^–2,.P <0.01). Ejection phase indices were normal in the patientgroup, while impaired left and right ventricular diastolic fillingwas found. In fact, isovolumic relaxation time was prolonged(118 ± 21 vs 78 ± 12 ms; P <0.001), ratio ofearly to late mitral (0. ± 0.3 vs 1.8±0.5 P<0.001)and tricuspid (1.0±0.2 vs 1.4±0.3 P<0.001 flowvelocities were significantly decreased as compared with controls.Superior vena cava flowmetry was also abnormal showing a markeddecrease of diastolic filling wave and, consequently, of theratio between peak diastolic and peak systolic flow velocity.No significant differences observed between normotensive andhypertensive acromegalics, except for left ventricular massindex (115 ± 20 vs 156 ± 31 g.m^–2; P <0.01).These findings indicate that abnormal diastolic filling patternsof transmitral, transtricuspid, and superior vena cava flowmetrysuggesting ‘impaired relaxation’ associated withincreased left and right ventricular mass, frequently occurin acromegaly.     

Multisite pacing for prevention of atrial tachyarrhythmias: potential mechanisms

OBJECTIVES

To determine the effects of single-, dual-, triple- and quadruple-site atrial pacing on atrial activation and refractoriness in normal canine hearts.

BACKGROUND

Multisite pacing has been suggested to be superior to single-site pacing for prevention of atrial tachyarrhythmias. However, the underlying electrophysiological mechanisms are undetermined at the moment, as is the rationale for the selection of pacing locations and the number of pacing sites.

METHODS

In 13 normal beagle dogs, an epicardial multielectrode (128 bipoles) and a multiplexer mapping system were used to reconstruct epicardial atrial activation patterns obtained during simultaneous stimulation from up to four electrodes located in the high and low right and left atrium, respectively. For all pacing modes (single-, dual-, triple- and quadruple-site pacing), total activation times and local effective refractory periods at eight randomly selected sites as well as local recovery intervals were determined. In a subgroup of five dogs, total epicardial activation times were also obtained during single-site septal stimulation (septal group).

RESULTS

Activation times and local recovery intervals were minimized by triple-site stimulation, whereas a fourth site did not produce further shortening. Septal stimulation produced epicardial activation times comparable to quadruple-site stimulation. Local refractory periods and their dispersion always remained unaffected. Functional conduction blocks apparent during single-site were found to resolve during multisite stimulation.

CONCLUSIONS

Multisite pacing can prevent functional conduction blocks by multidirectional excitation and a reduction in total activation time. Triple-site and, possibly, septal pacing modes are expected to be most efficient because both minimize total activation times and maximize the multidirectionality of excitation. In spite of unaffected local refractory periods, the shortening of local recovery intervals might homogenize atrial repolarization and, thus, contribute to the preventive effects of multisite pacing.     

Isolated right superior vena cava drainage into the left atrium: An uncommon cause of persistent hypoxia in a neonate

This report describes the case of a 13-day-old African American female with persistent hypoxia found to have an isolated right superior vena cava (RSVC) draining into the left atrium (LA) confirmed with contrast echocardiography.     

Percutaneous atrial septal defect closure in a child with interrupted inferior vena cava: successful femoral venous approach

Interrupted inferior vena cava (IVC) with azygous continuation to the superior vena cava (SVC) is a relatively common systemic venous anomaly. This anomaly can occasionally complicate transcatheter intervention by rendering more difficult the usual direct route to the systemic venous atrium afforded by femoral venous access. We report our experience with successful transcatheter closure of a large residual atrial septal defect (ASD) using the femoral venous route in a 3-year-old patient with heterotaxy syndrome of left isomerism type, dextrocardia, partial atrioventricular canal defect, and interrupted IVC with azygous continuation to the SVC.     

Permanent Pacing from a Left Ventricular Vein in a Patient with Persistent Left Superior Vena Cava and Absent Right Superior Vena Cava: Use of an Over-the-Wire System

In patients with a persistent left superior vena cava, placement of a permanent transvenous pacing lead for ventricular pacing via the left subclavian vein can be technically challenging. Permanent pacing was achieved in a patient with a persistent left superior vena cava and absent right superior vena cava using a left ventricular vein. Use of an over-the-wire lead system greatly facilitated this procedure.     

Total vascular hepatic exclusion for tumor resection: a new approach to the intrathoracic inferior vena cava through the abdominal cavity by cutting the diaphragm vertically without cutting the pericardium

For the resection of advanced liver tumors in which the tumor thrombus extends into the intrathoracic inferior vena cava (IVC) above the diaphragm, surgeons need very skillful techniques and much experience. However, after detachment of the line of fusion of the pericardium to the diaphragm (LFPD), the intrathoracic IVC can be exposed easily. We herein present this novel surgical method, an approach to the intrathoracic IVC through the abdominal cavity. A 66 year-old man was referred to our hospital because of high-grade fever. Computed tomography revealed a large tumor of the left hepatic lobe with tumor thrombus extending into the intrathoracic IVC through the left hepatic vein. Laboratory data showed elevated levels of alpha-fetoprotein (AFP) (726 ng/ml) and protein induced by vitamin K absence (114 AU/ml). The patient was diagnosed with hepatocellular carcinoma (HCC) of the left hepatic lobe with tumor thrombus extending into the IVC. He underwent left hepatectomy with partial resection of the IVC and intravascular tumor thrombectomy under total hepatic vascular exclusion (THVE) without the use of cardiopulmonary bypass (CPB). Before THVE, we approached the IVC through the abdominal cavity with vertical dissection of the diaphragm after detachment of the LFPD without cutting the pericardium or performing median sternotomy. This procedure could be very beneficial and helpful for many liver surgeons.     

Hepatocellular carcinoma with right atrial extension in a young patient with congenitally unguarded tricuspid orifice

We report a case of a young female patient with congenitally unguarded tricuspid orifice and underdeveloped pulmonary valve leaflets, who had developed severe right-sided congestive heart failure and cardiac cirrhosis early in life. She was admitted to our hospital with deterioration of dyspnea and abdominal tenderness. Hepatocellular carcinoma was diagnosed on the basis of computed tomography findings, high plasma alpha-fetoprotein levels and evidence of chronic hepatitis B viral infection. Transthoracic echocardiogram revealed a mass into the right atrium, considered to be an extension of the tumor.     

Right hepatic lobectomy and removal of inferior vena caval tumor embolus in a patient with hepatocellular carcinoma,using veno-venous bypass while preserving perfusion in the remnant liver: A case report

We describe a successful hepatectomy and the removal of a tumor embolus in a 43-year-old woman with hepatocellular carcinoma occupying the right lobe extending to the right branch of the portal vein and the inferior vena cava (IVC). Intraoperative echography revealed the tumor embolus in the IVC to originate from the main tumor via the right inferior hepatic vein, which extended cephalad from the confluence of the right hepatic vein to the IVC. Right hepatc lobectomy was performed via the anterior approach. Using femoro-axillary veno-venous bypass, we opened the IVC at the root of the inferior right hepatic vein to remove the tumor embolus after oblique clamping of the IVC between the right and middle hepatic veins was carried out to preserve perfusion in the remnant liver. Preserving perfusion in the remmant liver in radical hepatectomy for hepatocellular carcinoma with tumor embolism in the IVC appears to be a safe and advantageous technique in patients with poor liver reserve.     

The use of inferior vena cava filter as a treatment modality for massive pulmonary embolism. A case series and review of pathophysiology

The use of inferior vena cava (IVC) filter for massive pulmonary emboli (PE) with cardiopulmonary instability has not been clinically studied. We present a case series of six such patients who received an IVC filter with anticoagulation rather than thrombolysis because of high risk of bleeding. Acute pulmonary embolectomy was considered, but was not possible for a variety of individual clinical situations.These six hospitalized patients prospectively followed during their admission. They were triaged to three medical intensive care units (ICUs) and one surgical ICU in three university teaching hospitals. One patient was transferred from another institution. All six patients had severe hypoxia and tenuous cardiopulmonary status. All required high inspiratory oxygen and hemodynamic support; two required mechanical ventilation and vasopressors. An IVC filter was placed emergently and anticoagulation was started immediately All six patients had resolution of pulmonary thromboemboli (PTE) on anticoagulation while the IVC filter prevented further PE. All six patients were discharged home in their pre-critical illness state. None ofthe patients suffered complications from this therapy and had excellent resolution ofcardiopulmonary collapse. The IVC filter placement prevented further major embolic events while the PTE resolved with anticoagulation. An IVC filter should be considered as an adjunct to anticoagulation therapy for those patients with massive PE and cardiopulmonary instability who are not candidates for thrombolysis, and acute pulmonary embolectomy is not readily available or is of very high risk.     

Sudden cardiac death caused by migration of a TrapEase inferior vena cava filter: case report and review of the literature

CASE: A 43-year-old female presented with sudden onset of palpitations, chest pain, and shortness of breath associated with hypoxemia. A helical computed tomography (CT) scan of the chest revealed a large saddle pulmonary embolism. Intravenous tPA relieved the shortness of breath and improved the hypoxemia. Inferior vena cava (IVC) filter (TrapEase, Cordis Corp., Miami, FL, USA) was placed. On day 6 of her hospitalization, she went into cardiopulmonary arrest while walking back from the rest room. The patient died despite a prolonged attempt at cardiopulmonary resuscitation. At that time, ventricular tachycardia and then ventricular fibrillation were recorded. Autopsy of the heart showed the IVC filter entrapped within the tricuspid valve. DISCUSSION: The incidence of IVC filter migration ranges from 0.3 to 6% with rare migration to the heart or lung (0.1-1.25%). Sudden cardiac death from migration of IVC filter is extremely rare. We report the first case of sudden cardiac death caused by migration of the TrapEase filter to the heart. There are two reports in the literature of death from migrating Greenfield and Antheor filters. CONCLUSION: An IVC filter migration to the heart, although rare, can cause serious arrhythmia and sudden cardiac death.     

A case of primary gastric small cell carcinoma with a rare pattern of lymph node metastasis

We report a very rare case of primary gastric small cell carcinoma (GSCC) that was accompanied with gastric tubular adenocarcinoma. A male in his 60s had an elevated tumor with a central ulceration in the middle stomach. The patient underwent a distal gastrectomy with lymph node dissection. The pathological examination showed two separated lesions of the stomach, which contained the components of primary GSCC and primary gastric tubular adenocarcinoma. Immunohistochemical (IHC) examination demonstrated that the tumor cells in the small cell carcinoma stained positive for synaptophysin, chromogranin A, and neural cell adhesion molecule (NCAM). GSCC cells and adenocarcinoma cells independently metastasized to each regional lymph node. Further studies on the biological behavior of individual tumors may allow the development of new treatment strategies for GSCC.     

Esophageal metastasis of stem cell-subtype hepatocholangio carcinoma:Rare presentation of a rare tumor

Hepatocholangiocarcinoma(c HCC-ICC) is a rare primary hepatic tumor defined by the presence of histological features of both hepatocellular carcinoma(HCC) and intrahepatic cholangiocarcinoma(ICC). Its prevalence ranges from 1%-5% of all primary liver cancers. We report the case of a 55-year-old cirrhotic male patient admitted to our university hospital for dysphagia, revealing a 10 cm lower-third esophageal metastasis of an unresectable c HCC-ICC with stemcell features. Computed tomography and abdominal magnetic resonance imaging scans revealed multiple hepatic lesions combining features of both HCC and ICC, associated with synchronous bone metastasis. Histological and immunohistochemical analyses of biopsies from the esophageal lesion and the hepatic tumor confirmed the diagnosis of c HCC-ICC with a stem cell-subtype, according to the World HealthOrganization classification. After a multidisciplinary meeting, the patient was treated with chemotherapy. He received two cycles of a gemcitabine plus cisplatin regimen before bone progression, and he died 3 mo after the initial diagnosis.     

Resection of renal metastases to the pancreas: a surgical challenge

BACKGROUND: Metastasis to the pancreas from renal cell carcinoma (RCC) is distinctly uncommon. Most cases are detected at an advanced stage of the disease and are thus unsuitable for resection. A solitary RCC metastasis to the head of pancreas is rarely encountered and, although it is potentially amenable to surgical resection, surgeons may be hesitant to perform pancreatoduodenectomy. CASES OUTLINES: Two patients with a solitary RCC metastasis to the head of pancreas were treated by pancreatoduodenectomy, while a third with multiple RCC metastases declined any treatment. Two of the patients were asymptomatic, and one presented with anaemia and mild abdominal pain. Computed tomography (CT) and angiography were used to exclude other metastases and to assess resectability of the pancreatic tumour. All three patients are still alive, those with resectable disease at 2 years and 9 years and the one with irresectable disease at 4 years. DISCUSSION: Isolated RCC metastasis to the pancreas is a rare event. Patients present either on follow-up imaging or with symptoms such as mild abdominal pain, weight loss, jaundice, anaemia or gastrointestinal bleeding (whether occult or overt). Dynamic spiral CT can visualise the tumour and exclude distant metastasis. Angiography often reveals a highly vascularised tumour and will help to assess resectability. In the absence of widespread disease, pancreatic resection can provide long-term survival in metastatic RCC, although few cases have been reported with lengthy follow-up. The prognosis is better than for pancreatic adenocarcinoma.     

Congenital inferior sinus venosus defect associated with pulmonary valve stenosis: A late presentation of a rare disease

Congenital inferior sinus venosus defect (SVD) is a rare congenital heart disease. Proper diagnosis of this disease is challenging and requires understanding of cardiac hemodynamics. Here, we discuss a patient with a late presentation of combined congenital inferior SVD associated with congenital pulmonary stenosis.