[Extracorporeal Membrane Oxygenation for Anesthesia Induction in a Patient with Severe Cardiorespiratory Impairment due to Mediastinal Angiosarcoma]

BACKGROUND

Mediastinal angiosarcoma is a rare intrathoracic tumor that can cause severe pleural and pericardial fibrosis.

CASE REPORT

We report the anesthetic management for pericardiectomy and pleurolysis in a 33-year-old patient with a mediastinal angiosarcoma. He presented with severe restrictive ventilatory impairment and heart failure due to fibrosis of the pleura and pericardium. Spirometry indicated a forced vital capacity of 0.66 l, while arterial blood gas analysis under noninvasive positive pressure ventilation indicated hypercapnia (pH 7.44; Pa(CO2) 59.2 mmHg). His cardiac index was 1.36 l x min(-1) x m(-2). Anesthesia induction and positive pressure ventilation are associated with an extremely high cardiorespiratory risk; therefore, veno-arterial-extracorporeal membrane oxygenation (VA-ECMO) with femoral cannulation was started prior to anesthesia induction. After achieving a stable circulation and adequate gas exchange, anesthesia was induced, and mechanical ventilation with intratracheal intubation was initiated. With ECMO and inotropic support stable hemodynamics was maintained throughout anesthesia induction and the operation was performed uneventfully under cardiopulmonary bypass. The patient was extubated on the first postoperative day and discharged one month after the operation.

CONCLUSION

ECMO is a useful option to secure adequate gas exchange and circulation during anesthesia induction in patients with severe cardiopulmonary problems due to mediastinal tumors.

Ventricular tachycardia associated with radiation-induced cardiac sarcoma

Cardiac tumors can lead to distinct electrocardiographic changes and ventricular arrhythmias. Benign and malignant cardiac tumors have been associated with ventricular tachycardia. When possible, benign tumors should be resected when ventricular arrhythmias are intractable. Chemotherapy can shrink malignant tumors and eliminate arrhythmias. We report the case of a 52-year-old woman with breast sarcoma whom we diagnosed with myocardial metastasis after she presented with palpitations. The initial electrocardiogram revealed sinus rhythm with new right bundle branch block and ST-segment elevation in the anterior precordial leads. During telemetry, hemodynamically stable, sustained ventricular tachycardia with right ventricular localization was detected. Images showed a myocardial mass in the right ventricular free wall. Amiodarone suppressed the arrhythmia. To our knowledge, this is the first report of ventricular tachycardia associated with radiation-induced undifferentiated sarcoma. We discuss the distinct electrocardiographic changes and ventricular arrhythmias that can be associated with cardiac tumors, and we review the relevant medical literature.

Left atrial myxoma with versus without cerebral embolism: length of symptoms, morphologic characteristics, and outcomes

The aim of this study was to evaluate the embolic sequelae of left atrial myxomas and their influence on diagnosis, treatment, and prognosis. Seventy-eight patients were retrospectively investigated. According to their symptoms and neurologic-imaging findings, these patients were classified into 2 groups: embolism (15 patients, 19%) and nonembolism (63 patients, 81%). The time from the first onset of symptoms to diagnosis (that is, the duration of symptoms) was significantly longer in the embolism group than in the nonembolism group (105 ± 190 vs 23 ± 18 d; P <0.01). The myxomas were divided into 2 types on the basis of clinicopathologic findings: type 1, with an irregular or villous surface and a soft consistency, and type 2, with a smooth surface and a compact consistency. There were 42 patients with type 1 myxoma and 36 with type 2. Type 1 myxoma was more frequently found in the embolism group (12 patients, 29%) than was type 2 myxoma (3 patients, 8%). The difference was significant (P=0.04). There were 2 perioperative deaths in the nonembolism group. No recurrence of cardiac myxoma or death was recorded in either group during follow-up. In the embolism group, neurologic symptoms were relieved by surgery, and no subsequent neurologic event was reported. Because surgical resection is highly effective in left atrial myxoma, we should strive for early diagnosis in order to shorten the duration of symptoms and to avoid worse neurologic damage in patients in whom an embolic event is the initial manifestation.

T-cell prolymphocytic leukemia with extensive cardiovascular infiltrate leading to multiple myocardial infarctions and cardiac death

Lymphocytic neoplasm involving the heart is not common and usually presents with pericardial effusion or focal myocardial infiltration. Myocardial infarctions due to leukemic infiltration of the coronary arteries are rarely reported. We present the case of a 52-year-old Guatemalan man with a one-year history of untreated T-cell prolymphocytic leukemia. He was admitted to our hospital for chemotherapy and evaluation of a pulmonary cavitary lesion by wedge resection. During sedation, the patient experienced acute respiratory failure and hypovolemic shock, from which he could not be resuscitated. Autopsy revealed that leukemic cells extensively infiltrated the aorta, myocardium, and coronary arteries. The lumina of the 3 major coronary artery branches showed 70% to 95% stenosis, with multifocal remote myocardial infarctions. Tumor cells were also detected in the lungs and other organs. The acute cardiorespiratory insufficiency secondary to leukemia-particularly the extensive infiltration of the coronary arteries and myocardium, and the multiple myocardial infarctions-eventually resulted in cardiac death.

[Calcified amorphous tumor of the right atrium after open heart surgery; report of a case]

A 37-year-old woman, who had undergone surgery of atrial septal defect (ASD) at 12-year-old, developed bradycardia and referred to our hospital. Transthoracic echocardiography revealed high echoic tumor in the right atrium. The image of the tumor was of low intensity by T2 weighted magnetic resonance imaging (MRI) and floating mass with a stalk to the right atrium in cine MRI. She underwent tumor resection under cardiopulmonary bypass. Histopathologilal examination of the tumor was calcified amorphous tumor. The postoperative course was uneventful.

Tuberous sclerosis and cardiac tumors: new electrocardiographic finding in an infant

Cardiac rhabdomyoma, the primary cardiac tumor most often diagnosed in children, is frequently present in patients with tuberous sclerosis. Most pediatric patients with rhabdomyoma are asymptomatic; however, various electrocardiographic abnormalities can be detected, such as Wolff-Parkinson-White syndrome, ectopic atrial tachycardia, and atrioventricular node dysfunction. We describe the case of a 10-month-old infant girl who had tuberous sclerosis and multiple cardiac rhabdomyomas. Her electrocardiographic presentation was notable for dome-shaped T waves and no ST segment in some leads. To our knowledge, this electrocardiographic finding has not been described in patients with tuberous sclerosis and cardiac masses.

[Cardiac myxomas may cause cerebral aneurysms]

Cerebral aneurysm following a cardiac myxoma is a rare neurological complication. We report a 50-year-old man who developed cerebral aneurysms one year after resection of a cardiac myxoma. Magnetic resonance imaging of the brain showed features of intracranial haemorrhage. Digital subtraction angiography showed several fusiform intracranial aneurysms bilaterally in the middle cerebral artery. Finally, we discuss potential molecular mechanisms of the development of myxomatous aneurysms.

Fetal intracardiac rhabdomyoma in beckwith-wiedemann syndrome

Fetal cardiac tumors are a rare finding in prenatal ultrasonography. Most of them are rhabdomyoma, which are thought to be pathognomonic for tuberous sclerosis complex. We present an infant with prenatally diagnosed cardiac rhabdomyoma (CR), who was found to suffer from Beckwith-Wiedemann syndrome (BWS). This congenital overgrowth syndrome is characterized by macrosomia, macroglossia, omphalocele, hypoglycemia, and hemihypertrophy. BWS patients have an increased risk for formation of benign and malignant tumors, typically intra-abdominally located, but, to the best of our knowledge, fetal CRs have not been reported before. BWS must be added to the list of differential diagnoses and to the prenatal counseling of the parents in cases of prenatal detection of CR.

Spindle cell sarcoma of the mitral valve: an unusual cause of acute coronary syndrome in a child

We present an unusual case of acute myocardial infarction by embolic obstruction of both the left anterior descending and right coronary arteries in a 14-year-old girl. Echocardiography showed mobile lesions on the mitral valve and into the left ventricular outflow tract with poor left ventricular function, eventually suggesting endocarditis. Successful surgery comprised mitral valve plasty after complete resection of the tumoral lesion, in association with coronary artery embolectomy. Histologic examination revealed a malignant spindle cell sarcoma treated with adjuvant chemotherapy. We emphasize here the differential diagnosis of acute coronary syndrome in children by a rare cardiac tumor.

Metastatic carcinoid tumor--atypical presentation

Carcinoid tumor is a slow-growing type of neuroendocrine tumor, originating in the enterochromaffin cells and secreting mainly serotonin. Neuroendocrine tumors (NETs) are found throughout the intestinal tract, the appendix and terminal ileum being the most common locations, and are classified by site of origin and by degree of differentiation, with well-differentiated lesions representing those tumors formerly referred to as carcinoid tumors. The clinical symptoms are characterized by flushing, diarrhea, abdominal pain, and/or bronchial constriction and occur almost exclusively in patients with liver metastases due to the release of bioactive peptides and amines directly into the systemic circulation. We report the clinical, serological and histological diagnosis of a 67-years-old male patient with congestive heart failure secondary to carcinoid heart disease in the context of liver metastases of an ileum carcinoid tumor.

[Papillary fibroelastoma of the left ventricular outflow tract complicated with acute coronary syndrome; report of a case]

We experienced a case of papillary fibroelastoma (PFE) that was incidentally diagnosed along with acute coronary syndrome( ACS). An 83-year-old female with paralysis of the left leg was diagnosed with acute coronary syndrome(ACS) based on an increased level of cardiac troponin I and ST elevation in the chest lead on electrocardiogram(ECG). On an echocardiogram, the patient was found to have a mobile mass that was likely to be a cardiac tumor. Coronary angiography showed 99% stenosis in the middle left anterior descending coronary artery. We performed emergent coronary aortic bypass graft(CABG) and excision of the tumor. The tumor was attached to the left ventricular outflow tract wall beneath the right coronary cusp with a sea anemone appearance. The histopathological findings revealed a papillary fibroelastoma. The patient's postoperative course was uneventful.

Cavernous hemangioma of the mitral valve in an adult male patient successfully treated with surgical resection: a case report

Cavernous hemangioma is a very rare benign primary cardiac tumor that commonly involves any part of the heart, having been found in the atria, ventricles, interventricular septum, pericardium, and epicardium. A predominant location in the avascular cardiac valves is extremely rare, however. The case is reported of a 48-year-old male with recurrent anginal chest pain who subsequently underwent coronary angiography that revealed a mobile, rounded mass at the mitral valve which was fed by the left circumflex artery. Echocardiography revealed a left atrial echogenic mass attached to the posterior leaflet of the mitral valve. Histopathology of the mass following its surgical resection was consistent with hemangioma of the cavernous type. The patient recovered uneventfully. To the present authors' knowledge, this is the first reported case of cavernous hemangioma of the mitral valve in an adult male to be successfully treated with surgical resection.

Neovascularization and associated fistula formation in a left atrial myxoma: evaluation with multidetector computed tomography

Although angiographically detectable neovascularity is being reported with increasing frequency in patients with cardiac myxoma, associated coronary fistula to the cardiac chamber has not been described. We report a 62-year-old woman in whom cardiac computed tomography (CT) enabled the noninvasive diagnosis of a left atrial myxoma with neovascularization arising from the left circumflex artery and the formation of an unusual fistula into the left atrial cavity, with concomitant evaluation of the coronary arteries. Careful suture ligation of a supplying coronary branch in the atrial septum was performed during tumor excision to prevent the development of intra-atrial steal.

[Successful excision of a left ventricular fibroma in an adult patient; report of a case]

A 55-year-old man was referred with a diagnosis of a left ventricular thrombus. Echocardiography revealed that he had a thrombus in the free wall of the left ventricle. Under cardiopulmonary bypass, we removed the intramural tumor. After the removal, the defect was repaired by Dor operation. Pathological examination revealed the tumor was a cardiac fibroma. He is doing well without any troubles 3 years after the operation.

Recurrent right ventricular cardiac myxoma in a patient with Carney complex: a case report

INTRODUCTION

Carney complex is a multiple neoplasia syndrome involving cardiac, endocrine, neural and cutaneous tumors with a variety of pigmented skin lesions. It has an autosomal dominant mode of inheritance. Approximately 7% of cardiac myxomas are related to the Carney complex. Myxomas that occur as part of the Carney complex affect both sexes with equal frequency. Cardiac myxomas with Carney complex are reported mostly in the left side of the heart and are less common on the right side. As per our review, this is the first reported case of Carney complex with right ventricle cardiac myxoma.

CASE PRESENTATION

We present a rare case of recurrent cardiac myxoma in a patient later diagnosed to have Carney complex. A 46-year-old Caucasian man with a history of thyroid hyperplasia came to out-patient cardiology department with new onset atrial fibrillation. A transthoracic echocardiogram revealed a right ventricular mass attached to his interventricular septum, which was later seen on a transesophageal echocardiogram and cardiac magnetic resonance imaging. He underwent resection of the ventricular mass which on pathology revealed myxoma. He later developed skin lesions, pituitary adenoma and Sertoli cell tumor suggesting Carney complex. Two years later he developed a new mass within his right atrium which was later resected.

CONCLUSIONS

Carney complex is a rare autosomal dominant disease with variable penetrance. Since it involves multiple organs, patients diagnosed with Carney complex should undergo serial endocrine workup, neural assessments, echocardiograms and testicular ultrasounds. Of the total number of cases of Carney complex, 65% are linked to PRKAR1A gene mutation. It is important for clinicians to be cognizant of a link between cardiac myxoma and Carney complex. The use of multi-imaging modalities allows better delineation of the mass before planned resection. Carney complex-related cardiac myxoma comprises 7% of all cardiac myxomas. Right ventricular cardiac myxomas are rare. This case report is the first to describe right ventricular myxoma with Carney complex.

AIDS-related primary cardiac lymphoma with right-sided heart failure and high-grade AV block: insights from magnetic resonance imaging

A 44-year-old patient, with personal history of AIDS, was referred to our emergency unit with tachycardia and moderate signs of right-sided heart failure. The cardiac MRI study showed an impairment of the right ventricular free and inferior wall and the interventricular septum. The mass was characterized by notable heterogeneity with mixed areas of hypo- and hypersignal intensity in SSFP and T2-weighted images with fat saturation. There was global hyperenhancement of the mass after gadolinium contrast injection on T1-weighted images with and without fat saturation. The entire right coronary artery was included into the infiltrative mass. One day after the admission, the patient suddenly presented a paroxysmal third degree atrioventricular block, permanently corrected by an implanted cardiac pacemaker. Endomyocardial biopsy conformed the diagnosis of B-cell lymphoma. The patient died 4months after the diagnosis of acute heart failure with multi-organ dysfunction, after a short period of improvement under chemotherapy. We present this case to highlight the importance to consider that a large, solitary, right atrial mass in conjunction with pericardial effusion in a patient with HIV infection should lead to consider, as soon as possible, the diagnosis of lymphoma. MRI has explained the conduction disorders by showing the septal extension of the mass, and by demonstrating right coronary artery involvement.

Ascites--rare manifestation of right atrial myxoma

Right atrial myxoma is less commonly found. Ascites is a rarer clinical presentation of such myxoma. Sometimes, practicing doctors are unable to detect causes of transudative ascites. In such situation, a high index of suspicion is needed to arrive at the correct diagnosis of right atrial myxoma giving rise to ascites.

Left atrial appendage myxoma masquerading as left atrial appendage thrombus

Myxomas are the most common benign tumors of the heart. They can arise from any heart chamber, but have rarely been described as originating from the left atrial appendage. We describe a case of left atrial appendage myxoma mimicking a left atrial appendage thrombus, and presenting with microembolization to the coronaries.

[Primary cardiac angiosarcoma in the right atrium with cardiac tamponade]

Primary cardiac angiosarcoma is very rare with an incidence of 0.0017∼0.19% in collected autopsy series, and its prognosis has been reported as being extremely poor( average survival of 6∼9 months). A 56-year-old man was referred to our hospital with cardiac tamponade caused by right atrial angiosarcoma, after initially being misdiagnosed as acute type A dissection. Echocardiography and chest computed tomography (CT) revealed a pedunculated tumor with a broad base which was originating from the right atrial wall and extended into atrio-ventricular (AV) groove. The tumor was completely resected, and a bovine pericardium patch was used for cardiac reconstruction. Histological examination showed angiosarcoma and a sign of radical excision. The patient, who made an uneventful recovery,was given postoperative radiotherapy and chemotherapy. He died of multiple systemic metastases 14 months postoperatively despite of multidisciplinary treatment. We discuss the therapeutic strategies available for this highly malignant cardiac tumor.

A patient with lung squamous cell carcinoma presenting with severe cardiac dysfunction similar to dilated cardiomyopathy with left bundle branch block induced by myocardial metastasis

A patient with severe cardiac dysfunction similar to dilated cardiomyopathy expired because of lung squamous cell carcinoma. He was admitted with respiratory failure and was diagnosed with congestive heart failure due to dilated cardiomyopathy based on the chest X-ray, electrocardiography, echocardiography, and coronary angiography. Chest computed tomography showed a mass shadow in the right lower lobe, and the patient was diagnosed with lung squamous cell carcinoma by bronchoscopy. The patient expired, and the autopsy revealed that a myocardial metastasis disrupted the cardiac-conduction system without dilated cardiomyopathy in myocytes. Left bundle branch block caused by myocardial metastasis presumably induced left cardiac dysfunction.

Left atrial myxoma detected after an initial diagnosis of polymyalgia rheumatica

We herein report the case of a 69-year-old woman with left atrial myxoma detected following treatment with glucocorticoids for an initial diagnosis of polymyalgia rheumatica (PMR). The glucocorticoids markedly improved the patient's symptoms, and the tumor was excised after rapidly tapering the glucocorticoid dose. The PMR-like symptoms did not recur and the inflammatory marker levels returned to normal after surgery. The patient's clinical course indicated that the initial PMR-like symptoms were entirely caused by the left atrial myxoma. This case demonstrates that glucocorticoid treatment for suspected PMR can mask the symptoms of myxoma, leading to a delay in diagnosis.

Life-threatening acute heart failure due to primary cardiac undifferentiated pleomorphic sarcoma

A 41-year-old man was admitted with acute heart failure and shock status. An echocardiogram showed a mobile tumor obstructing blood flow through the mitral valve with a stalk on the posterior left atrium (LA) wall. Emergent open-heart surgery was performed to resect the tumor (77×36×30 mm). Histological examination confirmed that it was an undifferentiated pleomorphic sarcoma. Unfortunately, positron emission tomography performed five months after surgery demonstrated a local recurrence around the right pulmonary vein and LA. We performed proton beam radiotherapy to treat the local recurrence, and it was effective. The patient has survived more than one year since the first life-threatening heart failure episode.

Cardiac involvement in CD56 negative primary pancreatic extranodal NK/T-cell lymphoma, nasal type, presenting with ventricular tachycardia during the early stages of chemotherapy

We herein report the case of a 23-year-old man who presented with recurrent pancreatitis and was diagnosed with primary pancreatic extranodal natural killer/T-cell lymphoma, nasal type, involving the right ventricle. The cardiac involvement was screened and confirmed by transthoracic echocardiography (TTE), cardiac magnetic resonance imaging and fluorodeoxyglucose positron emission tomography. Although the patient did not have any cardiac symptoms or evidence of arrhythmia before chemotherapy, he presented with fatal newly developed ventricular tachycardia during the early stages of chemotherapy. The follow-up TTE after his chemotherapy demonstrated markedly decreased thickness of the invaded myocardium, thus suggesting that the myocardium infiltrated by lymphoma cells might become vulnerable to fatal arrhythmia with tumor regression.

A patient with primary pericardial synovial sarcoma who presented with cardiac tamponade: a case report and review of the literature

A 36-year-old man presented with near-syncope. He was found to have massive pericardial effusion with a giant pericardial tumorous lesion. The pericardial effusion exhibited a bloody nature; however, neither malignant cells nor infectious organisms were detected. (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed an increased uptake of FDG in the pericardial tumor only. Although the tumor was not resectable, thoracotomy and tissue sampling were performed. A histological analysis showed CD99 positivity and SYT gene rearrangement, leading to a diagnosis of synovial sarcoma arising from the left lateral pericardial surface. The patient is now receiving chemotherapy.

Recurrent stroke in a case of left atrial myxoma masquerading vasculitis

We report a case of left atrial myxoma presenting as recurrent neurological deficits with absent peripheral pulses mimicking systemic vasculitis. Due to absence of cardiac signs and symptoms, there was one year delay in diagnosis from initial symptom. Left atrial myxomas are rare but treatable cause of recurrent stroke.

[Attainment of complete hematological remission is crucial for extended survival of AL amyloidosis patients with cardiac involvement]

BACKGROUND

Symptomatic cardiac involvement is the most important prognostic factor in AL amyloidosis patients. Longterm survival is limited not only by cardiac involvement condition, but also by limited choice of treatment with unsatisfactory results. The aim of the present report is to assess the effect of achieved treatment response on survival of AL amyloidosis patients with symptomatic cardiac involvement under conventional treatment.

MATERIAL AND METHODS

The monitored patient set consisted of 19 patients with systemic AL amyloidosis and symptomatic cardiac involvement, treated and monitored at the III. Clinic of Internal Medicine between 2004 and 2012. The male : female ratio was 17 : 2, and the age median was 64 (range 48 to 78 years). Thirteen patients died within the monitored period. Functional status was defined according to the NYHA classification, where five patients had class II involvement, 10 patients had class III involvement, and four patients had class IV involvement. Treatment response was assessed by the application of modified IMWG and ISA criteria; all patients were undergoing conventional treatment. Nine patients were treated by a combination of alkylating agents (alkeran, cyclophosphamide), six were treated by a combination treatment with thalidomide, and four were treated by a combination of bortezomib and dexamethasone. Data were analyzed with software SPSS v. 15 (SPSS, Inc., Chicago, USA). Log Rank Test was applied to survival evaluation.

RESULTS

The statistical analysis included only 13 patients who underwent at least three months of treatment, where six patients attained complete remission (CR), four patients attained partial remission (PR), and three patients attained only stabilization of disease (SD). Significant difference in patient survival was found to be correlated with attained hematological response, where the patients who attained CR had median survival of 39 months vs 10 months in patients who attained PR or SD (p = 0.005).

CONCLUSION

The results indicate that attainment of complete hematological remission is associated with significantly longer survival of AL amyloidosis patients with symptomatic cardiac involvement.

[Surgical management of metastatic colon cancer causing obstruction of the right ventricular outflow tract]

Metastatic cardiac tumors are commonly detected during autopsy. However, they are seldom diagnosed during life, and surgical resection is rarely indicated. Among the malignant tumors, colon cancer rarely metastasizes to the heart. We report a case of a 70-year-old woman with sigmoid colon cancer, which metastasized to her heart and caused obstruction of the right ventricular outflow tract. The tumor had already metastasized to the liver, lungs, periaortic lymph nodes, and peritoneum. Cardiopulmonary bypass surgery was performed to excise the right ventricular metastatic tumor and to reconstruct the tricuspid valve. Histological analysis of the specimen confirmed a metastatic adenocarcinoma. Although this surgery was performed as palliative cancer therapy, the patient's symptoms were satisfactorily improved. Follow-up echocardiography 2 months after her cardiac surgery showed no space-occupying mass in the right ventricle.

[Infracentimetric nodule of the mitral valve in a young patient with stroke]

Primary cardiac tumors of the cardiac valves are very rare in clinical practice. Early diagnosis and therapeutic orientation are crucial, as these tumors can cause great morbidity and mortality. In this article we report a case of an infracentimetric nodule of the mitral valve, causing a stroke in a young patient, which is the starting point for a literature review of the diagnostic and therapeutic orientation of these rare lesions.

Cardiac leiomyosarcoma, a case report

In this case report we present the history of a patient admitted with recurrent pulmonary edema. Transesophageal echocardiography showed a tumour in the left atrium, occluding the ostium of the mitral valve and mimicking intermittent mitral stenosis. Cardiac surgery followed by pathological examination revealed that the tumour was a leiomyosarcoma. Images from the echocardiography as well as the pathological findings are shown and discussed. The present case report illustrates that atrial tumors comprise also sarcomas, suggesting the use of careful, rapid diagnostic procedures and treatment to prevent dissemination of malignancy.

Atrial myxoma: a rare cause of ischemic stroke

Arial myxoma can present as stroke and should be considered as a differential diagnosis of stroke in young individuals. We present here a 42 years female who presented with sudden loss of conciousness. After extensive work up for young stroke, left atrial myxoma was detected and tumor was removed surgically and histopathological report was consistent with the atrial myxoma.

[Left atrial myxoma with a coronary artery steal syndrome due to the coronary artery to left atrial fistula; report of a case]

A 73-year-old woman with dyspnea was diagnosed with a left atrial myxoma by echocardiography. Right and left circumflex coronary angiography showed neovascularity in the tumor and the blood flow jet extending from the tumor to the left atrial cavity, which led to the steal phenomenon in the left anterior descending artery. Surgical excision of the left atrial tumor and the maze procedure were performed with a cardiopulmonary circuit. To our knowledge, this is the 1st study to report the development of the coronary artery steal syndrome due to a cardiac myxoma. Exercise testing would involve risks such as embolism and left ventricular inflow disturbance; furthermore, the presence of concomitant chest symptoms with cardiac myxoma is not rare. Therefore, preoperative coronary angiography would be used for differential diagnosis and for detecting the coronary artery disease, which is reported to be common in patient with cardiac myxomas.

Right atrial angiosarcoma with severe biventricular dysfunction and massive pericardial effusion

This paper presents the case of a 35 year-old woman with symptoms of heart failure from the last month. A physical examination at admission showed paleness, dyspnea, peripheral edema and fatigue. In a two-dimensional echocardiography and transesophageal echocardiography, normal thickness but severe left and right ventricular dysfunction with severe pericardial effusion and thickened pericardium were found. In the enlarged right atrium, an oval-shaped structure was found with features of continuity with lateral right atrial wall and also a bulging of the structure through the orifice of the tricuspid valve to the right ventricle. In the echocardiography, we did not saw any blocking of the tricuspid valve or the inflow from inferior vena cava (IVC) or superior vena cava (SVC) or coronary sinus. On the basis of the echocardiography examination and clinical presentation, tentative diagnosis of the right atrium myxoma was made. A coronary angiography revealed normal coronary arteries and no feeding of tumor by branch of right coronary artery (RCA). Surgical removal of the tumor was performed without complication. The histopathological examination confirmed the diagnosis of angiosarcoma. In the follow-up echocardiography carried out after three months, severe left ventricular (LV) and right ventricular (RV) dysfunction continued and was demonstrated. Magnetic resonance imaging revealed no lymphadenopathy or re-growth of the tumor in the mediastinum or pericardium.

Molecular genetic, cardiac and neurodevelopmental findings in cases of prenatally diagnosed rhabdomyoma associated with tuberous sclerosis complex

OBJECTIVE

Rhabdomyoma is the most common type of cardiac tumor in fetuses and is often associated with tuberous sclerosis complex (TSC) with neurologic sequelae. The purpose of this study was to investigate the cardiac and neurodevelopmental outcomes of fetal rhabdomyoma.

METHODS

We reviewed the clinical characteristics of 23 cases of cardiac rhabdomyoma diagnosed prenatally by fetal echocardiography at the Asan Medical Center between January 1998 and December 2009. We also reviewed postnatal results of brain magnetic resonance imaging, echocardiography, renal ultrasound examination and molecular genetic analysis to confirm the presence of cardiac rhabdomyoma with or without TSC.

RESULTS

Among 23 cases, outcome data were available for 17 (73.9%) and six cases (26.1%) were lost to follow-up. The survival rate was 100.0% (17/17). Among the 17 cases with outcome data, spontaneous tumor regression occurred in eight (47.1%), and no change in tumor size and number was observed in the remaining nine cases (52.9%). There was no evidence of long-term cardiac dysfunction caused by persisting rhabdomyomas, regardless of tumor size. TSC was found in nine patients (52.9%), of whom five (55.6%) showed neurodevelopmental morbidity. We identified mutations in one of the TSC1 or TSC2 genes in four of nine TSC infants whose parents allowed us to perform molecular genetic analysis. Three of these (75.0%) were found to have neurologic impairment. Seven (77.8%) of nine TSC cases were non-familial.

CONCLUSIONS

The overall outcome of isolated cardiac rhabdomyoma appears to be favorable. We suggest that systematic postnatal evaluation of TSC be performed even in cases of cardiac rhabdomyoma without a family history of TSC. Molecular characterization of TSC1 and TSC2 might be helpful in predicting short- and long-term neurodevelopmental outcomes.

An unusual case of giant cardiac fibroelastoma mimicking left atrial myxoma in a patient presenting with syncope

Cardiac papillary fibroelastomas are the most common primary valvular tumors. Generally benign, they account only for about 10% of all primary cardiac neoplasms, can occur in normal or diseased hearts, and are associated strongly with open heart surgery and radiotherapy. They are, in most cases, incidental findings, but can be discovered after syncope. We report the case of an elderly female, who was referred for syncope and was found to have a large fibroelastoma at the mitral valve annulus, intermittently obstructing the left ventricular inflow tract, and mimicking the presentation of left atrial myxoma. This case illustrates another potential mechanism of syncope in patients with fibroelastomas.