Successful resection of the right atrial myxoma with excessive tumor vascularity in a elderly patient

A 72-year-old female underwent successful resection of a giant right atrial myxoma. The patient had slight cough with abnormal cardiac silhouette and elevated ESR. The diagnosis of right atrial myxoma was established by echocardiography and angiography. Venacavography revealed huge mass which occupied in the entire right atrium. This tumor was perfused by well developed feeding arteries arising from both right and circumflex coronary arteries, and showed rich tumor vascularity. This tumor was resected with the interatrial septum and the free wall of the right atrium which were attached with tumor. Interatrial septal defect was closed with a Teflon fabric patch and the defect of right atrial free wall was approximated by direct closure with Z-plasty. Postoperative course was uneventful. Pathological examination showed myxoma without invasion into the resected septum and atrial wall. It is important to prevent tumor embolization to the pulmonary artery or strangulation into the right ventricle during surgery on this type of huge right atrial myxoma.     

Reconstruction of the right atrium with pulmonary artery homograft after resection of right atrial lipomatosis

We present a case of large right atrial mass due to lipomatous hypertrophy of the interatrial septum and left lower lobe adenocarcinoma. Combined resections of the right atrial mass with reconstruction of the superior atriocaval junction and right atrial free wall defects with pulmonary artery homograft and wedge excision of the lung tumor were performed through median sternotomy.     

Intracardiac varix of the left atrium

A 68-year-old female patient with a history of hyperlipidaemia and fatty liver was referred for evaluation of an incidentally detected asymptomatic cardiac mass. Computed tomographic scan imaging showed a large calcified mass in the left atrium. Echocardiography revealed a 2.4 1.5 cm, well-circumscribed, round, high echoic mass with severe calcification and low mobility attached to the lower rim of the fossa ovalis. The cardiac mass along with part of the fossa ovalis and left atrial wall were excised. Histological diagnosis was compatible with intracardiac varix.     

Hemodynamic consequences of right ventricular isolation: the contribution of the right ventricular free wall to cardiac performance

Surgical isolation of the right ventricular free wall was performed in 10 dogs to evaluate both the hemodynamic effects of the procedure and the postoperative contribution of right ventricular free wall contraction to overall cardiac performance. Following the procedure, there was no significant differences in peak right ventricular systolic pressure, right atrial pressure, right ventricular stroke volume, or cardiac index. Cardiac index remained at preoperative levels over a wide range of filling pressures. However, there was a significant decrease in right ventricular stroke work (6.0 +/- 1.3 gm-m/m2 to 5.1 +/- 0.5 gm-m/m2; p less than 0.05). Pacing the isolated right ventricular free wall resulted in marked hemodynamic improvement compared with an electrically silent right ventricular free wall. Cardiac index increased from 1.7 +/- 0.2 L/min/m2 to 2.6 +/- 0.2 L/min/m2 (p less than 0.0005), and right ventricular stroke work went from 3.0 +/- 0.6 gm-m/m2 to 6.4 +/- 0.9 gm-m/m2 (p less than 0.0005). Right ventricular performance was also significantly related to the timing of right ventricular free wall contraction. Thus, the right ventricular free wall played an important role in the maintenance of normal cardiac hemodynamics.     

Surgical treatment of right ventricular hydatid cyst

Hydatid cyst is a serious endemic parasitic disease found in cattle-raising areas of the world. Cardiac hydatid cysts are rare and appear in 0.5% to 2% of hydatid cyst cases. A 24-year-old male patient was admitted to the hospital because of chest pain. A cystic mass (4 4 3 cm) was demonstrated with transthoracic echocardiography, computed tomography, and magnetic resonance imaging. A hydatid cyst was located in the right ventricular wall near the inferior branch of the acute marginal branch of the right coronary artery and was located such that it pushed the tricuspid valve inward. The cystic materials were removed with the patient on cardiopulmonary bypass. The surgery for cardiac hydatid disease is safe, and the results are satisfactory.     

Right atrial angiosarcoma: a case report

A 32-year-old female patient presented with dyspnea and palpitation, and transthoracic echocardiography revealed the presence of pericardial effusion. Pericardiosynthesis was performed for drainage. Because of the rapid accumulation of effusion and the presence of a right atrial mass on follow-up echocardiography, a computed tomography scan was done that revealed a right atrial defect and the presence of advanced pericardial effusion. The patient was prepared for an emergency operation. The mass on the right atrial wall was approached via a midsternal incision with cardiopulmonary bypass. The tumor filled the right atrial cavity, compressed vital structures, extended to the right ventricle, and had local metastases. As the tumor did not appear to be curable with surgery, a palliative approach was adopted. The right atrial free wall and tissues causing cardiac obstruction were totally removed, the tumor itself was partially excised, and local metastases were sampled. The resulting right atrial wall defect was closed with a Dacron patch. The operation ended uneventfully, and the clinical status and vital and hemodynamic findings of the patient returned to normal. The pathological diagnosis based on the samples obtained during the operation was angiosarcoma. The patient had an uneventful postoperative period and was then referred to an oncology center for clinical recovery. No findings of local recurrence or metastases were observed during the postoperative follow-up. The patient completed her combination therapy and currently is free of any clinical problems at her 13th postoperative month. We believe that advancements in radiotherapy and chemotherapy regimes combined with surgery (radical, if possible) for the treatment of cardiac angiosarcomas may provide better survival and quality-of-life results.     

Papillary fibroelastoma of the right atrium: an atypical presentation. A case report and review of the literature

Papillary fibroelastomas are a rare form of benign cardiac neoplasm. While the majority of these lesions are asymptomatic and found incidentally via echocardiography or cardiac catheterization, those occurring on left-sided structures may become clinically important producing symptoms of syncope, angina, myocardial infarction, and sudden death. These masses also have the propensity to embolize resulting in transient ischemic attacks and strokes. Most papillary fibroelastomas are found on valvular structures and currently there are only 4 published case reports of these lesions occurring in the right atrium. Of these reports, only 3 have been presented as arising on the right atrial free wall. This case report presents the 54th known case of a papillary fibroelastoma occurring in the right atrium and the 4th to be reported as developing from the right atrial free wall. A review of the literature as well as the histogenesis, diagnosis, and therapy of this rare entity are discussed.     

A rare disappearing right atrial mass

Cardiac tuberculosis is rare and usually involves the pericardium. Myocardial tuberculoma is a very rare occurrence and only a few cases have been reported. We describe a rare case of cardiac tuberculoma involving the whole of the lateral right atrial wall, extending from the superior vena cava/right atrial junction up to a tricuspid valve. The initial diagnosis of right atrial myxoma was made based on the echocardiography report and surgical excision was planned. Intraoperatively, the excision of the mass was deferred due to the extensive nature of the disease and a high suspicion of malignancy. Cardiac tuberculoma was confirmed by histopathological examination. The patient made a remarkable recovery with the complete disappearance of the mass after anti-tuberculous treatment, as viewed by a postoperative echocardiography during the follow-up.     

Successful surgical treatment of a mycotic right coronary artery aneurysm complicated by a fistula to the right atrium

We reported successful surgical treatment of a mycotic right coronary artery aneurysm complicated by a fistula to the right atrium in a 60-year-old man admitted to hospital because of acute worsening of renal function and erythroderma. After admission, he suffered from methicillin-resistantStaphylococcus aureus septicemia. Despite administration of vancomycin hydrochloride, a low-grade fever persisted. Subacute cardiac tamponade occurred three months after admission, and acute inferior wall myocardial infarction occurred two weeks after pericardial drainage. An emergent coronary angiography demonstrated a large saccular aneurysm of the right coronary artery forming a fistula to the right atrium and obstruction of the distal right coronary artery. We emergently resected the aneurysm including the right atrial wall and repaired the defect in the right atrium. Pathological examination of the aneurysmal wall revealed its mycotic nature; the postoperative course was uneventful. (Jpn J Thorac Cardiovasc Surg 2005; 53: 661–664)     

Extensive cardiac infiltrative melanoma

We report an unusual clinical case of a 66‐year‐old patient with cardiac involvement from a metastatic melanoma, causing the formation of a large right atrial mass with extensive infiltration of the right atrial free wall, the interatrial septum, the coronary sinus, and up to the mitral annulus and posterior wall of the right ventricle, unamendable to complete surgical excision. As secondary cardiac tumors are not part of routine daily clinical practice, we thought that this clinical case would be a good educational opportunity for the practicing clinicians, both specialists and nonspecialists.     

Aggressive invasive recurrence of a right atrial myxofibrosarcoma

A 58‐year‐old man presented with left‐sided chest discomfort 9 years ago. At that time a 12‐centimeter extrapleural mass was resected via left thoracotomy. Surgical pathology revealed a low‐grade myxofibrosarcoma. Since that time, he had undergone three separate resections of recurrent left extrapleural masses with sternotomy and thoracotomy. He proceeded to have a five‐year disease‐free interval after which a pericardial mass invading into the right atrial free wall, the atrioventricular groove, and the right coronary artery was identified. Surgical resection was performed with negative margins and the right atrium and atrioventricular groove were reconstructed without any residual tricuspid regurgitation.     

Right atrial metastasis from hepatocellular carcinoma

A 65-year-old patient with a past medical history of hypertension, alcoholism, micronodular cirrhosis, and coronary artery bypass grafting 10 years ago developed a hepatocellular carcinoma, treated by chemoembolization. One month after treatment, thoracoabdominal CT scan showed no residual hepatic tumor, but tumoral aspect in the right atrium with extension into the inferior vena cava. The patient being asymptomatic, cardiac ultrasound confirmed the presence of a free, mobile, pediculated tumor in the right atrium. Surgical exploration found a well-circumscribed mass, attached to the atrial wall by a 1.5-cm diameter pedicle implanted near the inferior vena cava ostium, moving freely in the right atrial cavity. The tumor was easily resected by section of the pedicle and its surrounding parietal implantation zone. No complications occurred postoperatively, and the patient was discharged on the 10th postoperative day. Three years after, the patient is in good health and is asymptomatic; cardiac ultrasound showed no tumor recurrence.     

Pedunculated hemangioma in the right ventricle

We report a rare case of right ventricular hemangioma. In an asymptomatic 56-year-old man, echocardiography as a part of medical checkup demonstrated a pedunculated tumor, 1.0 x 1.3 x 1.5 cm, arising from the free wall of the right ventricle. No findings were seen of a feeding artery to the tumor or vascular blush in preoperative coronary angiography. Successful resection was done through right atriotomy under total cardiopulmonary bypass. The histological examination revealed capillary hemangioma. The postoperative clinical course was uneventful, but requires careful follow-up for possible coronary cardiac fistula. This is the fifth case of right ventricular hemangioma, to our knowledge, ever reported in Japan.     

Primary echinococcus cyst of the heart. A case report

A young male commercial pilot, completely asymptomatic of heart disease, was found to have an abnormal ECG on routine examination. This consisted of a bifascicular block (left anterior hemiblock plus a complete right bundle-branch block). Aviation regulations demanded further examination to rule out possible cardiac disease. On two occasions in 1984 and again in 1986 cardiac catheterisation was performed and revealed normal left ventricular function and normal coronary arteries. On 15 April 1986 an echocardiogram revealed a large cystic mass in the right ventricle, which was further delineated by right-sided cine-angiography. The patient was referred for cardiac surgery with the diagnosis of an Echinococcus cyst as the most likely possibility. Open-heart surgery was performed on 16 July 1986 and a 4 x 4 cm hydatid cyst, originating from the right ventricle septum and projecting into the right ventricular cavity, was removed. The diagnosis of Echinococcus granulosus was confirmed by histological examination.     

Radical correction of paracardiac type IIb of total anomalous pulmonary venous connection using pedicled flaps of right atrium and atrial septum

Surgical results of total anomalous pulmonary venous connection (TAPVC) has been improved in recent years, however, late development of pulmonary venous obstruction was our concern in its total correction in early infancy. In the cardiac type of TAPVC, in which the pulmonary veins were connected to the right lateral wall, prosthetic patch is conventionally used in diversion of pulmonary venous flow into left atrium. It seemed favorable to repair this subset without using prosthesis. A 3-month-old female with TAPVCIIb according to Darling's classification underwent total correction on September 22th, 1988. Two pedicled flaps were developed using the right atrial wall and the atrial septum to create a pulmonary venous channel to divert arterial blood into left atrium and absorbable sutures were used throughout. Right atrium was entered through a vertical incision in its body and all the pulmonary veins were found in a recess in the lateral wall of the right atrium. Atrial septal defect in the cranial aspect of the fossa ovalis was enlarged by cutting the primum tissue along the right limbus and its caudal margin so as to form a pedicled flap attached to the left limbic tissue. Then the flap was sutured along the limbus to create a roof of the fossa ovalis. The second flap was made in the middle of the lateral atrial wall and was used to create a tunnel from the recess to the atrial septal defect. The defect in the right atrial wall was closed directly and no prosthetic patch was used. Postoperative course was uneventful and echocardiogram showed wide pulmonary venous channel draining into the left atrium.     

Limitations of transesophageal ultrasound in the assessment of intracardiac masses: a case report

A 72-year-old man who had been treated for 20 years with warfarin for auricular fibrillation was scheduled for resection of a sessile mass (3.5 x 4 cm) on the posterior wall of the left atrium and a smaller mass (1.5 x 2 cm) in the right atrium. The masses were diagnosed by transthoracic ultrasonography and computed tomography. After anesthetic induction, a tube was inserted for transesophageal ultrasound guidance during resection of the masses. During surgery, the presence of a large mass was confirmed on the posterior wall of the left atrium, which was enlarged due to chronic fibrillation. The smaller, mobile, pediculated mass attached to the right free wall of the atrium or to the tricuspid valve was also confirmed. Given these findings and the patient's history, differential diagnosis with either biatrial myxoma or thrombus was considered. After opening both atria, an organized thrombus in the left atrium and a large hypertrophic trabecula in the trabeculated portion of the right atrium was found to be responsible for the misleading ultrasonographic image suggesting masses.     

Bronchogenic cyst of the right hemidiaphragm presenting with pleural effusion

Bronchogenic cysts are developmental foregut anomalies usually located within the mediastinum or lung parenchyma. An isolated bronchogenic cyst of the diaphragm is very rare. Our case was a 56-year-old female patient who presented with pleuritic chest pain in her right chest. Chest and abdominal computed tomography revealed a large lobulated cystic mass that was accompanied with pleural effusion in the right lower hemithorax. The tumor showed focally calcified areas in the wall and abutted against the diaphragm. We performed complete excision of the cyst including a portion of the diaphragm attached to it. The pathological diagnosis was established as the bronchogenic cyst originating from the diaphragm. We report this case with a review of the literature.     

Reduction in pulmonary varix size after mitral valve replacement

A 48-year-old female was admitted to our hospital for examination of an abnormal shadow in the right lung field. She had a systolic murmur (4/6) over the apex and the chest radiograph revealed cardiac enlargement with three round opacities in the right lung field. Cardiac catheterization showed marked mitral regurgitation and large pulmonary varices. Pulmonary varix caused by mitral regurgitation was diagnosed. The size of the pulmonary varix was reduced with improvement of pulmonary artery wedge pressure one month after mitral valve replacement. We conclude that pulmonary varices can decrease in size secondary to lowering of left atrial pressure within one month after operation.     

Cardiac varix presenting as a right atrial mass

A cardiac varix is an unusual tumor of vascular origin that is rarely discovered antemortem. Here, we report the incidental finding of this lesion in the right atrium of a patient with concomitant prostate cancer.     

Usefulness of power Doppler ultrasound in a patient with renal cell carcinoma in the wall of a simple renal cyst]

We present a case of renal cell carcinoma in the wall of a simple renal cyst. A 54-year-old man visited our hospital with a complaint of right back pain. Ultrasound study revealed right hydronephrosis, a ureteral stone, and a 9 x 8 cm renal cyst, with a tumor, 2 cm in diameter, in the cyst wall. Power Doppler Ultrasound and enhanced computed tomography demonstrated hypervascularity of the tumor. Clinically, he was diagnosed as renal cell carcinoma and nephrectomy was performed. Pathological findings of the tumor showed clear cell carcinoma in the wall of a simple renal cyst. Twelve months after the nephrectomy, he was free from recurrence.