Intractable pneumothorax secondary to pulmonary metastasis of angiosarcoma

A 68-year-old male suffered from right pneumothorax and was admitted to our hospital. He had a previous history of angiosarcoma of the scalp, and had received local resection and chemoradiotherapy. Chest computed tomography (CT) on admission revealed right pneumothorax and bilateral multiple thin-walled cavities of the lung. We performed partial resection of right lung. Histopathological examination showed a small metastatic lesion around the thin-walled cavities of the lung. Four months after the 1st lung resection, he suffered left pneumothorax. We performed partial resection of the left lung. Ten days after the 2nd lung resection, left pneumothorax recurred. Nine days later, he also developed right pneumothorax. We performed the 3rd operation for right lung. Thoracoscopy demonstrated multiple bullas in right lung and it showed impossibility for radical surgery. Although surgical resection for pneumothorax secondary to metastatic lung cancer is usually efficient, it is very hard to manage the pneumothorax of metastatic angiosarcoma.     

Angiosarcoma causing cardiac rupture

We report the 7th known case in the literature of cardiac angiosarcoma resulting in cardiac rupture. A 34-year-old woman was admitted presenting chest pain and pericardial effusion. After the patient had been treated for 3 months under the diagnosis of pericarditis of unknown etiology, she became hypotensive. Doppler echocardiography showed increased pericardial effusion and a communication between the right atrium and the pericardial cavity. An emergency operation was undertaken to drain the effusion and explore the etiology. We found the ruptured right atrium and the irregularly shaped tumor extending from the pericardium near the inferior caval vein to the right ventricle. There was no apparent tumor on the right atrium, but its wall was extensively thin, which we replaced with autologous pericardium. The patient died on the 44th postoperative day. Clinical diagnosis of cardiac angiosarcoma is usually very difficult. If Doppler echocardiography demonstrates pericardial effusion and find a ruptured right atrium with or without mass formation, we should suspect cardiac angiosarcoma.     

Cardiac angiosarcoma with right atrial perforation and cardiac tamponade.

Primary cardiac angiosarcoma is a rare tumor associated with a poor prognosis. We report a case of a 59-year-old woman with right atrial angiosarcoma presenting with cardiac tamponade due to right atrial perforation. She underwent urgent surgical resection of the tumor. However, the patient died 68 days after surgery due to local recurrence. An effective treatment for cardiac angiosarcoma has not yet been established. However, more aggressive treatment with a combination of surgery, radiation, chemotherapy and IL-2 should be considered.     

Giant cardiac metastasis of myxoid liposarcoma causing cardiac tamponade; report of a case

We report a very rare case of cardiac metastasis of myxoid liposarcoma. A 55-year-old man presented with dyspnea. Two and a half years ago, he underwent resection of myxoid liposarcoma in the left thigh. Magnetic resonance imaging (MRI) revealed a giant tumor occupying the pericardiac cavity and pressing the heart and consequently causing cardiac tamponade. The patient underwent surgery through a left thoracotomy approach. The pericardiac cavity was filled with a giant tumor with a stalk from the right ventricle and 2 small nodules on the main pulmonary artery. He was relieved from the symptom: however, he had a recurrence of the tumor at the same site 5 months after the operation. He underwent surgery for the removal of the second tumor; however, he died 49 days after the operation. Although cardiac metastasis is a very rare condition, its awareness is essential for careful long-term follow-up for the early detection of a metastatic cardiac liposarcoma after the resection of the primary tumor.     

A Case of Primary Cardiac Angiosarcoma: Extensive Right Atrial Wall Reconstruction with Autologous Pericardium

Abstract Primary cardiac angiosarcoma is a rare and aggressive tumor. Diagnosis is usually late because of the rarity of the lesion and the nonspecific clinical symptoms. We report the case of a 48‐year‐old man affected by angiosarcoma of the right atrium who presented with subacute cardiac tamponade. Extensive resection of the atrial wall infiltrated by the tumor, followed by autologous pericardial free atrial wall reconstruction, was successfully carried out. In spite of the optimal early outcome, the patient died 15 months later because of multiple osteal metastases . (J Card Surg 2010;25:282‐284)     

Rupture of the diaphragm and pericardium with cardiac herniation after blunt chest trauma

A 61-year-old man was transferred to our institution because of blunt chest trauma after accidentally falling. A chest roentgenogram (CXR) and computed tomography (CT) revealed bilateral hemopneumothorax and fractures of multiple left ribs, the pelvis, and the left femur. On the second day in hospital, the patient suddenly complained of dyspnea. Emergency CXR and CT revealed elevation of the left diaphragm, suggestive of a traumatic diaphragmatic hernia; emergency surgery was performed. We confirmed rupture of the diaphragm and pericardium with cardiac herniation: the pleural pericardium and diaphragm were torn individually, and the heart and abdominal organs had herniated into the pleural cavity. They were repaired, and there were no cardiopulmonary complications during or after the operation. Pericardiodiaphragmatic rupture with cardiac herniation after multiple blunt traumas is rare. We describe the successful treatment of a diaphragmatic and pericardial rupture with cardiac herniation, with special reference to pericardial injuries.     

Bronchioloalveolar carcinoma with acute respiratory failure due to hemoptysis; report of a case

A 69-year-old male was admitted to our hospital for hemoptysis and dyspnea. Because of his deteriorating respiratory distress, he was intubated and controlled by respirator for 3 days. He was diagnosed with adenocarcinoma of the lung by the sputum examination and chest computed tomography (CT) revealed an infiltration shadow in the peripheral superior ventral segment (S3) of the right upper lobe. He underwent right upper lobectomy with video-assisted thoracic surgery. Microscopic findings of the resected specimen measuring 10 x 10 x 7 cm revealed mucin-producing bronchioloalveolar carcinoma (BAC) with metastases in lymph nodes and the same lobe (S2b). We reported a rare case of BAC with hemoptysis.     

Recurrent brain abscess associated with congenital pulmonary arteriovenous fistula: a case report

We report a rare case of recurrent brain abscess associated with congenital pulmonary arteriovenous fistula. A 52-year-old man was admitted to our hospital in October, 1999 because of a sudden stroke-like onset of right hemiparesis, right hemiparesthesia, dysarthria and sensory aphasia. He had a history of previous brain abscess in the right cerebellar hemisphere. It had been removed in 1991. CT scan at the time of the current admission disclosed a low-density area in the left parietal region. The mass was ring-enhanced after injection of contrast medium. On MRI the mass lesion was depicted as low-intensity on T1-weighted image and high-intensity on T2-weighted image. The mass was ring-enhanced after administration of Gd-DTPA. In spite of conservative treatment the size of the abscess increased considerably with marked surrounding edema. The brain abscess was successfully treated with aspiration and drainage, and the residual mass was resected. The patient also had a history of arteriovenous fistula in the lower lobe of his right lung. This had been excised in 1965. However, he had no signs, symptoms or family histories of hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). Contrast enhanced CT scan of the chest showed nodular lesions connected to vascular shadows in the right lower lung field. Pulmonary angiograms also revealed multiple arteriovenous fistulas in the lower lobe of the right lung. He was not dyspneic or cyanotic, but his hypoxia, polycythemia, and recurrent brain abscess were thought to be caused by pulmonary arteriovenous fistula. The fistulas were embolized with coils via a percutaneous catheter. Pulmonary arteriovenous fistula should be treated aggressively either by surgery and/or by coil embolization in order to prevent the complication of brain abscess.     

Combined coronary intervention in heart-transplant patient with rapidly accelerated cardiac allograft vasculopathy

A 46-year-old man accepted for heart transplantation due to persistent cardiac failure from dilated cardiomyopathy underwent a transplant in Germany on July 13, 1995. The donor heart was suspected of coronary artery disease at explantation, but he could wait no longer because of his rapidly deteriorating hemodynamics. Postoperative coronary angiography revealed 25% stenosis of the left descending artery. He showed several episodes of minimal or moderate rejection postoperatively, and coronary angiography 15 months postoperatively showed rapidly accelerated cardiac allograft vasculopathy demonstrating triple vessel disease with multiple lesions. Percutaneous transluminal coronary angioplasty was successful on 2 coronary vessels, but immediately recurrent stenosis and new lesions involving the left main trunk occurred 6 weeks thereafter. Since he was financially unable to afford a second heart transplantation, quadruple coronary artery bypass grafting was conducted October 25, 1996. A biventricular assist device was used when he could not be weaned from cardiopulmonary bypass. He died of multiple organ failure 3 days after surgery.     

Combined coronary intervention in heart-transplant patient with rapidly accelerated cardiac allograft vasculopathy.

A 46-year-old man accepted for heart transplantation due to persistent cardiac failure from dilated cardiomyopathy underwent a transplant in Germany on July 13, 1995. The donor heart was suspected of coronary artery disease at explantation, but he could wait no longer because of his rapidly deteriorating hemodynamics. Postoperative coronary angiography revealed 25% stenosis of the left descending artery. He showed several episodes of minimal or moderate rejection postoperatively, and coronary angiography 15 months postoperatively showed rapidly accelerated cardiac allograft vasculopathy demonstrating triple vessel disease with multiple lesions. Percutaneous transluminal coronary angioplasty was successful on 2 coronary vessels, but immediately recurrent stenosis and new lesions involving the left main trunk occurred 6 weeks thereafter. Since he was financially unable to afford a second heart transplantation, quadruple coronary artery bypass grafting was conducted October 25, 1996. A biventricular assist device was used when he could not be weaned from cardiopulmonary bypass. He died of multiple organ failure 3 days after surgery.     

Concurrent intrapericardial–pulmonary hydatidosis: an unusual multisystem echinococcosis

A 46-year-old male presented with breathlessness for a few months. He had been operated twice for liver hydatid cysts and once for right pulmonary hydatid cysts at other hospitals. Now he was found to have one hydatid cyst in the upper lobe of the left lung and multiple hydatid cysts adjoining left heart border. On computed tomography (CT) scan chest and echocardiography, it was difficult to ascertain whether these cysts were pulmonary or intrapericardial. Left ventricular ejection fraction (LVEF) was 25%. Enzyme-linked immunosorbent assay (ELISA) was positive for hydatid. Left posterolateral thoracotomy revealed dead hydatid cyst in upper lobe of the lung that was removed. Infected mother hydatid cyst was encountered inside pericardial sac. Scores of daughter hydatid cysts, varying in size from 1 to 30 mm, were scooped out intact from the pericardial cavity. There was significant improvement in cardiac activity, once the tamponade effect of hydatid cyst was removed. Pericardium was about 1 cm thick with lot of purulent and necrotic slough. To prevent future constrictive pericarditis, subtotal pericardiectomy was done. Intrapericardial hydatid cyst should be kept in mind whenever it obscures the heart border and patient has features of cardiac tamponade. Early surgical intervention may be required in these cases.     

A case of cardiac tamponade shock due to bleeding from an advanced thymoma

Although thymomas are the most common anterior mediastinal neoplasm, those causing cardiac tamponade are unusual. To the best of our knowledge, only 13 cases have been proven in the English literature We report thymoma in a 66-year old man that caused cardiac tamponade, for which he underwent an emergency operation. On admission, he presented in a shocked state; his echocardiography results revealed pericardial effusion. Computed tomography scan indicated a thymoma infiltrating the right lung. Initially, pericardial drainage was performed through puncture; however, cardiac tamponade recurred next day. Pericardial drainage, thymectomy, and pericardiectomy were performed, but the tumor was incompletely resected. On postoperative day 2, right upper lobectomy was attempted but discontinued because of the impossibility to manipulate the pulmonary hilum, which was suspected to have tumor infiltration. He was discharged on the 27th day after the first operation, is alive at 10 months after surgery, and is under chemotherapy.     

Successful surgical excision of primary right atrial angiosarcoma

Primary cardiac angiosarcoma is a rare and aggressive tumor with a high incidence of metastatic spread (up to 89%) at the time of diagnosis, which restricts the indication for surgical resection to a small number of patients. We report the case of a 50-year old Caucasian woman with non-metastatic primary right atrial angiosarcoma, who underwent successful surgical excision of the tumor (with curative intent) and reconstruction of the right atrium with a porcine pericardial patch. However, after a symptom-free survival of five months the patient presented with bone and liver metastases without evidence of local tumor recurrence.     

A case of cardiac myxoma with multiple brain hemorrhage]

A case of cardiac myxoma with multiple brain hemorrhage is reported. A 57-year-old male had complained of lower abdominal pain, diarrhea and fever for 3 days. On admission, he was in a condition of disseminated intravascular coagulation and sepsis. An abdominal CT scan showed infarction in the right kidney and spleen and an echocardiogram also showed myxoma in the left atrium. Although he presented no neurological symptoms, the brain CT showed multiple brain hemorrhage in the bilateral brain hemispheres. Total resection of the tumor was carried out for the improvement of the patient's general condition. Vimentin, S-100 protein and neuron specific enolase was positive in immunological staining and the pathological diagnosis was myxoma. Postoperative recovery of consciousness was poor and left hemiparesis developed. CT showed the increase of hematoma but angiography showed no cerebral aneurysm. The symptoms improved with conservative therapy. However the enhanced lesion remained in the right parietal lobe and an operation was performed 5 months later. The myxoma cell could not be found in the pathological examination, so tumor embolism, cerebral infarction, hemorrhagic infarction due to DIC, hematoma enlargement caused by heparinization during operation were suspected to have occurred in this order without tumor growth.     

Catheter drainage of late cardiac tamponade guided by computed tomography

Delayed cardiac tamponade is an unusual but serious complication of cardiac surgery. Echocardiography and computed tomography (CT) are well established methods for the detection of pericardial effusions. Catheter insertion guided by CT has been used to accomplish non operative drainage of symptomatic postoperative pericardial effusion in seven cases. These patients were grouped into four types according to distribution of the fluid. General pericardial effusion around the heart is classified as type 1, effusion adjacent to the right side of the heart as type 2 and left side as type 3, effusion localized only at the apex as type 4. CT imaging is useful not only to localize and assess the size of the effusions, but also to select the way of catheter insertion. As the fluid might be trapped in compartments, for instance right-sided or left sided type, investigation of the pericardial spaces is important in planning a catheter pericardiocentesis.     

Ruptured aortic arch aneurysm with hemorrhagic cardiac tamponade; report of a case

The ruptured aortic arch aneurysm with cardiac tamponade is rare and has severely high mortality. We report a case of ruptured aortic arch aneurysm with cardiac tamponade. A 66-year-old man who had syncope attack was transferred to city hospital. Brain computed tomography (CT) showed no significant lesion and he admitted to our hospital for suspecting of aortic dissection. Chest CT showed ruptured aortic arch aneurysm and pericardial effusion. Emergent operation was done on the same day. It was found that the hematoma beneath the tunica adventitia existed at the distal arch and extended to the ascending aorta. Cardiac tamponade was caused by rupture of subadventitial hematoma in pericardial space. Aortic arch replacement was performed using selective cerebral perfusion under deep hypothermia. Postoperatively, he had no cerebral complication and was discharged uneventfully.     

Case with cardiac myxoma causing cerebral metastasis after cardiac tumor resection

We report a case of cardiac myxoma causing cerebral metastasis after cardiac tumor resection. A 68-year-old man with a cerebral infarction was admitted to our hospital. A cardioembolic source was suspected and echocardiography was performed. In that examination, a cardiac tumor was found in the left atrium. Tumor resection was performed urgently and his postoperative course was uneventful. After the operation he had no new episodes of cerebral deficit. However 6 months after the operation, he complained of headaches. The brain computed tomography (CT) showed there were multiple high-density areas. One of the tumors was resected and the tumor was diagnosed pathologically as metastasis of cardiac myxoma. Brain metastases were treated with 40.8 Gy whole-brain radiation therapy. As the result the tumors were effectively treated and reduced.     

Aortic valve regurgitation with aorto-right ventricular fistula following penetrating cardiac injury

Aortic valve perforation due to a penetrating cardiac injury is extremely rare, especially with an associated shunt between the right ventricle and the aortic valve. We report here the case of an 18-year-old male, who after suffering a chest stab injury, was seen at another institution where he underwent an emergency left anterolateral thoracotomy and right ventricular suture. During the following 30 days, his course was torpid, complicated by a ventilator-associated pneumonia and heart failure with acute pulmonary edema. Workup confirmed the presence of an acute aortic regurgitation due to perforation of the right coronary leaflet with an interventricular shunt. After implementing appropriate medical treatment, the valve was replaced with a mechanical prosthesis and the shunt was closed with an autologous pericardial patch.     

Malignant schwannoma metastasizing to the parenchyma of the brain--case report

A 48-year-old male presented with a very rare case of malignant schwannoma metastasizing to the parenchyma of the brain. He had undergone previous radical surgical resection of an abdominal wall tumor that was histologically confirmed as a malignant schwannoma. Five years later, the patient presented with metastases to the parenchyma of the brain and lung. A large mass at the left frontoparietal region was totally resected immediately after intratumoral hemorrhage. He recovered well and the lung metastasis was also removed, but he later developed further multiple metastases in the lung and brain.     

Recurrent cardiac hydatidosis in a child presenting as acute stroke

Cardiac echinococcosis is a rare but potentially life threatening condition, with surgery being the definitive treatment. We present the case of a 4 year boy who was diagnosed with concurrent pulmonary and left intraventricular hydatid cysts. He was operated for the same and advised prophylactic albendazole. After a symptom free interval of 8 months the child developed acute onset right sided hemiplegia, which was confirmed on magnetic resonance imaging (MRI) brain as acute left basal ganglia nonhaemorrhagic infarct. Also a recurrent pericardial hydatid cyst was visualized, which was assumed to be the embolic source for the stroke. We report this exceptional case of recurrent cardiac hydatidosis presenting as acute stroke.