[Value of pericardial biopsy in the etiologic diagnosis of pericardial diseases]

PURPOSE

To determine the value of pericardial biopsy as a complementary exam in the etiology of pericardial effusion.

METHODS

We analyzed retrospectively (from 1990 to 1997) 38 patients with pericardial effusion. The age ranged between 3 months and 79 years (mean 41.15 +/- 21.78 years). Pericardial biopsy was performed in all cases through a subxiphoid incision.

RESULTS

In 4 patients (10.5%) the biopsy was able to define etiology, 2 had tuberculosis and 2 neoplasias (1 undetermined adenocarcinoma, 1 mesotelioma). In 34 patients the biopsy showed non-specific chronic pericarditis.

CONCLUSION

Pericardial biopsy was not an effective method to determine the etiological diagnosis in pericardial effusion patients. We believe that we have to individualize the indication of pericardial biopsy especially if tuberculosis or neoplasia are suspected.

Myxoma of the left atrial appendage mimicking thrombus during aortic valve replacement

Echocardiographic characterization of cardiac masses involving the left atrium are defined by morphologic shape and appearance, site of attachment, type of margins, and presence or absence in the left atrial appendage. Most reports use location in the LAA as strong supportive evidence of thrombus, especially if associated with other suggestive findings (i.e., atrial fibrillation, spontaneous echo contrast, or both). Other reported masses (non-thrombi) in the left atrial appendage are considered extremely rare. We report a case of a patient with coexisting aortic stenosis and atrial fibrillation diagnosed intraoperatively by transesophageal echocardiography with myxoma of the left atrial appendage.

Reduced serum T3 level in a patient with nodular goiter and cardiac myxoma

We report the unusual case of an 87-year-old woman with cardiac myxoma and adenomatous goiter. She exhibited slight elevations of serum interleukin-6 (IL-6), but levels of thyroid hormones such as T3, free T3 and free T4 were all abnormally low. Interleukin-6 may potentiate the alteration of thyroid metabolism.

Neonatal advanced heart block due to cardiac tumor

We describe a unique case of a child who, since birth, has had a heart tumor at the atrioventricular junction associated with second degree atrioventricular block. The tumor is probably a rhabdomyoma.

Cardiac rhabdomyomas and obstructive left heart disease: histologically but not functionally benign

BACKGROUND

Cardiac rhabdomyoma is the most common primary heart tumor in infants. Spontaneous regression of such tumors is common, particularly with smaller lesions, followed by resolution of symptoms. Based on our data on spontaneous involution, our institutional philosophy has been one of expectant management in the absence of life-threatening symptoms. However, surgical intervention sometimes is required for the extirpation of a rhabdomyoma from the left ventricular outflow tract.

METHODS

A retrospective review was conducted of 30 children in whom a rhabdomyoma was diagnosed over a 27-year period.

RESULTS

Twenty-three percent (7/30) of the children required surgical extirpation of the tumor from within their left ventricular outflow tract, although a total of 94% had left ventricular involvement. There were no deaths. To date, no child has required reexcision of tumor.

CONCLUSIONS

The natural history of rhabdomyoma is one of spontaneous regression (the 23 children who did not undergo surgical intervention are alive and continue to be followed up medically). We recommend surgical excision to alleviate acute outflow tract obstruction with reliance on the tumor's natural history of regression to achieve long-term freedom from reoperation. Although operation has been recognized as lifesaving, we were somewhat surprised to find that greater than 20% of our pediatric population required operative intervention.

Analysis of prognostic indicators for dogs with pericardial effusion: 46 cases (1985-1996)

OBJECTIVE

To determine factors associated with disease-free interval and survival time for dogs with pericardial effusion.

DESIGN

Retrospective study.

ANIMALS

46 dogs.

PROCEDURE

Signalment, history, results of physical examination, electrocardiography, echocardiography, and thoracic radiography; disease-free interval; and survival time were obtained from medical records or telephone conversations with owners and referring veterinarians.

RESULTS

Dogs that had ascites at the time of the initial physical examination were significantly less likely, and dogs that had evidence of pulmonary metastases on thoracic radiographs or that had echocardiographic evidence of a right atrial mass were significantly more likely, to have died of pericardial effusion or the underlying cause of effusion than were dogs that did not. Median survival time was 15.3 months for dogs with idiopathic pericardial effusion, 16 days for dogs with hemangiosarcoma, and 13.6 months for dogs with mesothelioma. Dogs that had a nonspecific extracardiac mass and underwent pericardiectomy were significantly less likely to have had recurrence of signs than were dogs that did not. However, dogs with mesothelioma or hemangiosarcoma that underwent pericardiectomy did not have a significantly different risk of recurrence of signs or survival time, compared with dogs that did not.

CLINICAL IMPLICATIONS

Results suggest that pericardiectomy will not affect risk of recurrence or survival time in dogs with pericardial effusion secondary to hemangiosarcoma or mesothelioma. However, pericardiectomy is still needed to differentiate dogs with neoplastic pericardial effusion from dogs with idiopathic pericardial effusion.

Atrial myxoma syndrome mimicking Ehrmann-Sneddon syndrome

Livedo racemosa with cerebrovascular lesions has been described as Ehrmann-Sneddon syndrome. The etiopathogenetic factors provoking the vascular lesions, however, are of high diversity reaching from mechanical to autoimmune causes. We present a male patient with typical livedo racemosa, muscle pain and feeling of coldness of the forearms. By dermatohistopathology and magnetic resonance tomography of the brain, Ehrmann-Sneddon syndrome could be confirmed. At this time a chronic streptococcal infection could be diagnosed. Antibiotics, anticoagulants and vascularity-supplying therapy improved the clinical and subjective symptoms. Six months later, the patient developed dizziness, vision disorder, hypesthesia of the right forehead, malaise and weight loss. A further diagnostic workup including echocardiography revealed a myxoma of the left atrium. This report illustrates the association of Ehrmann-Sneddon syndrome with cardiac myxoma and points out that cardiac diagnostic examination should be included when dealing with small-vessel involvement of the brain.

Fatal pulmonary embolization of a right atrial mass during transesophageal echocardiography

Transesophageal echocardiography is a semi-invasive diagnostic technique with a very low incidence of significant complications. Only two deaths related to the procedure have been reported in the literature. We present the case of a 46-year-old man with a right atrial mass, presumably a cardiac myxoma. During attempts at esophageal intubation for a transesophageal echocardiography procedure, the mass fragmented and dislodged, causing massive pulmonary embolism and death. We believe that to avoid this potential complication, great care must be taken in the evaluation of patients with a right intracardiac mass by means of transesophageal echocardiography.

MRI imaging of a left atrial mass misinterpreted by transesophageal echocardiography

Magnetic resonance imaging of the heart was used in a patient with a history of recurrent episodes of transient ischemic attacks in whom a left atrial mass was suspected on transesophageal echocardiography. The use of MRI clarified a diagnosis of a diaphragmatic hernia.

Primary cardiac leiomyosarcoma growing rapidly and causing right ventricular outflow obstruction

Leiomyosarcomas are extremely rare primary cardiac tumors. We report a rapidly growing primary leiomyosarcoma of the right ventricle, which obstructed the right ventricular outflow tract within one month after symptom onset in a 68-year-old man. Two-dimensional echocardiography was useful in diagnosing the extent and progression of the tumor. The tumor was surgically resected on an emergency basis, and the right ventricle and pulmonary artery were successfully reconstructed. Recurrence of the tumor on the right ventricle was observed, and the patient was overcome by sudden dyspnea and died three months after surgery.

Renal carcinoma presenting as cardiac tamponade: a case report and review of literature

Pericardial involvement in an advanced malignancy is common but malignancy presenting as cardiac tamponade is rather uncommon. Review of English literature using Medline CD ROM revealed 131 cases since 1935, who have presented with this life threatening emergency. Lung is the most common primary site followed by lymphomas and leukemias. We report a case of transitional cell carcinoma of kidney presenting as cardiac tamponade. Such a presentation of transitional cell carcinoma of kidney has never been reported.

[Cerebral infarction, pseudolupic syndrome and myxoma of the left atrium]

Left atrial myxomas are a rare stroke etiology (0.4%). They frequently present general symptoms such as fever, weight loss and an inflammatory syndrome, but the pseudolupic syndrome with cutaneous features and vasomotor symptoms is rarely described. We report the case of a 38-year old man who presented in March 1995 a stroke caused by a left atrial myxoma. There was also pseudolupic clinical and biological manifestations which disappeared after ablation of the myxoma. Cerebral angiography showed a small carotid aspect which evoked carotid dissection or carotid siphon occlusion. The authors discuss neurologic and pseudolupic manifestations of left atrial myxomas, and their physiopathologic mechanism.

Primary mitral valve sarcoma in infancy

Primary cardiac sarcoma is a rare tumor, found especially in children, particularly in the left side of the heart. This report describes a rare case of primary mitral valve sarcoma in a 7-month-old male infant with hemiparesis and heart murmur who underwent mitral valve replacement because of excessive invasion of the mitral valve by the tumor. The patient remains well, free of recurrence and cerebral metastasis, and without adjuvant therapy 18 months after the operation.

Cardiac malignant lymphoma: a case report

A 76 year old man, who had undergone tonsillectomy for non Hodgkin's malignant lymphoma, died suddenly in rapidly evolving cardiogenic shock with electrocardiographic signs of acute lateral myocardial infarction. Post mortem examination showed three cardiac lesions, two in the left ventricle and one in the right atrium, corresponding to the "crista terminalis". Histologic examination of autopsy samples confirmed the presence of lymphoma in the heart, partially affecting the sino atrial node (NSA) but excluding other sites. There was no evidence of acute myocardial infarction in spite of the clinical signs and symptoms. An infarction-type electrocardiographic pattern associated with conduction disturbances in patients with lymphoma should suggest the possibility of cardiac localization of the disease.

[Rhabdomyoma of the right ventricle associated with Behcet disease simulating the presence of a malignant tumor]

OBJECTIVE OF THE STUDY

To present the clinical case of a patient suffering from a rhabdomyoma associated to Behçet's disease.

PATIENTS

A 35-year-old man with a history of high fever associated to oral ulcers, sinus tachycardia, leukocytosis and a high erythrocyte sedimentation rate. Physical examination, chest x-ray, blood chemistry, serology and rheumatic tests were normal. Seriate sputum cultures, urocultures and blood cultures were negative. The echocardiogram showed a non-obstructive mass in the right ventricle, which was confirmed by magnetic resonance imaging.

INTERVENTIONS

Resection of the tumor under cardiopulmonary bypass. After the post-operative recurrence of the fever and the appearance of genital ulcers, the diagnosis of Behçet's disease was made. Two and a half years after the operation the patient remains asymptomatic under treatment with colchicine.

CONCLUSIONS

The clinical setting suggested a malignant tumor of the right ventricle but the pathological findings showed an adult rhabdomyoma. The rarity of finding a rhabdomyoma in an adult is stressed, as well as its association with Behçet's disease.

[Morphological observations of tumors in the cardiac conduction system]

OBJECTIVE

To investigate the incidence of tumors in the cardiac conduction system (CCS) and to study their relation to sudden deaths.

METHODS

The CCS from 149 cases of sudden death without extracardiac cause of deaths and those from 737 cases of non-cardiac death were sampled using technique designed by the authors. Routine histological examinations were carried out.

RESULTS

Tumors in the CCS were found in 12 cases (1.35%). Another case with tumor in the CCS was found in a specimen received for consultation. Of these 13 tumors, 10 were primary benign tumors affecting the CCS, 3 were metastatic tumors. The benign tumors included fibroma, hemangioma, lipomatous hypertrophy of the atrial septum, mesothelioma and rhabdomyoma. 8 of the 10 cases were located in the SAN or AVN. All the metastatic tumors were in the SAN. Of the 13 cases, 3 died suddenly.

CONCLUSION

Tumors in the CCS are the smallest tumors which can cause sudden death.

[Papillary fibroelastoma. A rare etiology of strokes in young patients]

BACKGROUND

The papillary fibroelastomas are cardiac lesions, which typically occur on the cardiac valves, but rarely on the endocardium. The incidence of these benign primitive tumors varies from 0.002 to 0.33% and increases with advancing age.

METHODS

We report two cases of stroke, one in a 31-year-old man and the other in a 48-year-old woman, both admitted to the same stroke center.

RESULTS

The diagnostic studies were normal in these two patients, except for the echocardiography. The first showed an echogenic mass on the mitral valve on transthoracic echocardiography (TTE), confirmed by the transesophageal echocardiography (TEE). The second demonstrated a mass on the sigmoid aortic valve on TEE, but the TTE was normal. For these two patients, a surgical excision was carried out and pathologic examination concluded to a papillary fibroelastoma. After surgery, no recurrence was observed.

CONCLUSIONS

The papillary fibroelastomas are usually asymptomatic and easily detected by TEE. However, it can be revealed by stroke, myocardial infarction and lower limbs ischemia. These cardiac tumors should be surgically removed, since their complete excision remains the only means of avoiding a recurrence of embolism.

[Left atrial myxoma and coronary embolism]

The authors report the case of a 49 year old man referred for a preoperative evaluation of a left atrial myxoma. During the hospital admission, the patient had an episode of sudden anginal chest pain associated with electrocardiographic changes of anteroseptoapical myocardial infarction. Emergency coronary angiography showed occlusion of the middle segment of the left anterior descending artery whereas it had been absolutely normal on the coronary angiogramme performed a few days beforehand. The diagnosis of coronary embolism from the left atrial myxoma was made and an emergency coronary angioplasty was performed followed by surgical ablation of the tumour.

Tuberous sclerosis complex and Wolff-Parkinson-White syndrome

This report highlights the association between tuberous sclerosis and Wolff-Parkinson-White syndrome. Ten patients with concurrent diagnoses of Wolff-Parkinson-White syndrome and tuberous sclerosis were identified. Wolff-Parkinson-White syndrome presented early in life, nine cases being diagnosed in the first year. Eight of the 10 cases were male. In eight cases, the syndrome was associated with supraventricular tachycardias, and in nine with cardiac rhabdomyomata. One child died from cardiac failure secondary to obstruction of the left ventricular outflow tract by a rhabdomyoma. Five of nine survivors showed resolution of Wolff-Parkinson-White syndrome on follow up. The accessory pathway was localised in nine patients from surface electrocardiograms: six children had left sided pathways and three had right sided pathways.

Primary cardiac lymphoma: death from cardiac asystole after attaining second complete remission

A patient with primary high grade cardiac lymphoma, diagnosed by pericardial fluid cytology, achieved complete remission with chemotherapy. After a relapse 11 months later, a second complete remission was attained with radiotherapy and chemotherapy but the patient suffered a fatal cardiac asystole during intensification therapy. A review of the recent literature suggests that prognosis for this rare extra nodal lymphoma has markedly improved as a result of early diagnosis and prompt institution of aggressive antilymphoma therapy.