Remission of "mistletoe sign" after treatment

Surgical planning aided with 3D technologies for management of complex paracardiac tumors

BACKGROUND

Accurate diagnosis and treatment of complex cardiac tumors poses challenges, particularly when surgical resection is considered. 3D reconstruction and printing appear as a novel approach to allow heart teams for optimal surgical and post operative care.

METHODS

We report two patients with uncommon masses including a cardiac angiosarcoma (CAS) and a IgG4-related disease (IgG4-RD) with exclusive cardiac involvement. In both cases, three-dimensional (3D) reconstruction and 3D-printed models were utilized to aid the surgical team achieve optimal pre-operative planning. Both patients underwent ECG-gated cardiac computed tomography angiography (CCTA) imaging and, due to the complex anatomy of the masses, their large dimensions, proximity to vital cardiac and vascular structures, and unclear etiology, computational and 3D-printed models were created for surgical planning. An exploratory literature review of studies using 3D-printed models in surgical planning was performed.

RESULTS

In case 1 (CAS), due to the size and extension of the mass to the right ventricular free wall, surgical intervention was not considered curative and, during thoracotomy, an open biopsy confirmed the imaging suspicion of CAS which guided the initiation of optimal medical treatment with chemotherapy and, after clear tumor retraction, the patient underwent a second surgical intervention, and during the 18 months of follow-up showed no signs of recurrence. In Case 2 (IgG4-RD), the patient underwent uncomplicated total surgical resection; this allowed directed treatment and, at 12 months follow-up, there are no signs of recurrence. Computational and 3D-printed models were used to plan the surgery and to confirm the findings. Limited studies have explored the use of 3D printing in the surgical planning of tumors.

CONCLUSIONS

We present two patients with uncommon cardiac tumors, highlighting the significant value of 3D models in the anatomical characterization and assessment of their extension. These models may be essential in surgical planning for complex cardiovascular cases and could provide more information than conventional imaging modalities. Further studies are needed to demonstrate the impact of 3D technologies in studying cardiac tumors.

Solitary recurrence of IgG4-related giant coronary aneurysm: Case report and review of the literature focusing on treatment strategies and complications

Coronary periarteritis is a dangerous manifestation of IgG4-related disease, because it forms coronary artery aneurysms, which may cause sudden cardiac death. We report the case of a 78-year-old woman with IgG4-related coronary periarteritis and a coronary aneurysm, which showed progressive enlargement despite maintenance therapy for Type 1 autoimmune pancreatitis. This case was unique, in that coronary periarteritis was the only active lesion that recurred. Low-dose glucocorticoids suppressed the progression of periarterial lesions but led to rapid thinning of the aneurysmal wall and an increase in the size of mural thrombi, which pose a risk of myocardial infarction. Our systematic literature review including 98 cases of 86 articles was performed to examine its treatment strategies and complications. Among the cases in which the effect of immunosuppressive therapy could be followed radiologically, 33 of 37 (89.1%) cases showed improvement in wall thickening/periarterial soft tissue, while 6 of 13 (46.2%) showed worsening increase in the outer diameter of the coronary aneurysms. We propose a draft treatment algorithm and suggest that immunosuppressive therapy for IgG4-related coronary periarteritis with coronary aneurysms should be conducted only after the therapeutic benefit has been determined to outweigh the risks. Because coronary periarteritis can occur without other organ involvement, as in our case, all cases of IgG4-related disease require careful monitoring of coronary artery lesions.

Case Report: Dual-Energy Computed Tomography of Cardiac Changes in IgG4-Related Disease

Background

Dual-energy computed tomography (DECT) is used in coronary plaque characterization, myocardial perfusion imaging, and pulmonary embolism diagnosis; however, there is no relevant research on DECT in IgG4-related diseases (IgG4-RD) involving the coronary artery. We are the first to report DECT findings of cardiac morphology and function in IgG4-RD.

Patient Findings

Multimodality cardiovascular imaging from a 63-year-old male patient, who presented with IgG4-related pancreatitis, was analyzed. An iodine map and spectral curves were obtained from the DECT, which can help to distinguish between non-calcified plaques and IgG4 lesions of the coronary artery, noninvasive FFR_CT (fractional flow reserve derived from coronary computed tomography angiography) and ECV (extracellular volume fraction) demonstrated myocardial ischemia and myocardial fibrosis, respectively.

Conclusion

The DECT can detect coronary artery tumor-like lesions caused by IgG4-RD and simultaneously assess the morphological, functional, and histological characteristics of the myocardium. This may help to guide individualized and timely treatment and avoid potentially life-threatening complications.