Primary cardiac tumors

Clinical characteristics and surgical outcomes of cardiac myxoma: A meta-analysis of worldwide experience

Cardiac myxoma is the most common primary cardiac tumor. However, existing literature mainly consists of single-center experiences with limited subjects. This systematic review aimed to provide data on clinical characteristics and surgical outcomes of cardiac myxoma. We performed a thorough literature search on May 23, 2023 on PubMed, ProQuest, ScienceDirect, Scopus, and Web of Science. The inclusion criteria were English full-text, observational studies, and included >20 subjects. From the search, 112 studies with a total of 8150 patients were included in the analysis. The mean age was 51 years (95 % confidence interval [95%CI] = 49.1-52.3), and the majority were females (64.3 % [95 % CI = 62.8-65.8 %]). The most common clinical manifestation was cardiovascular symptoms. Echocardiography can diagnose almost all cases (98.1 % [95 % CI = 95.8-99.6 %]). Cardiac myxoma was mostly prevalent in left atrium (85.3 % [95%CI = 83.3-87 %]) and predominantly with pedunculated morphology (75.6 % [95%CI = 64.1-84.3 %]). Post-tumor excision outcomes were excellent, with an early mortality of 1.27 % (95 % CI = 0.8-1.8 %), late mortality rate of 4.7 (95 % CI = 2.5-7.4) per 1000 person-years, and recurrence rate at 0.5 (95 % CI = 0.0-1.1) per 1000 person-years. Tumor excision is warranted in a timely manner once the cardiac myxoma diagnosis is established.

National outcomes following benign cardiac tumor resection: A critical sex-based disparity

BACKGROUND

Treatment of benign primary cardiac tumors involves surgical resection, but reported outcomes from multi-institutional or national databases are scarce. This study examines contemporary national outcomes following surgical resection of benign primary atrial and ventricular tumors.

METHODS

The 2016-2018 Nationwide Readmissions Database was queried for all patients ≥18 years with a primary diagnosis of benign neoplasm of the heart who underwent resection of the atria, ventricles, or atrial/ventricular septum. Primary outcomes were 30-day mortality, readmission, and composite morbidity (defined as stroke, permanent pacemaker implantation, bleeding complication, or acute kidney injury). Multivariable analysis was used to identify independent predictors of worse outcomes.

RESULTS

A weighted total of 2557 patients met inclusion criteria. Mean age was 61 years, 67.9% were female, and patients had relatively low comorbidity burdens (mean Charlson Comorbidity Index 1.39). The majority of patients underwent excision of the left atrium (71.5%), followed by the intra-atrial septum (26.6%), right atrium (2.9%). There was no difference in 30-day mortality (2.1% vs. 1.3%, p = .550), 30-day readmission (7.0% vs. 9.1%, p = .222), or 30-day composite morbidity (56.8% vs. 53.8%, p = .369) between females and males, respectively. However, on multivariable analysis, female sex was independently associated with increased risk of 30-day mortality (adjusted odds ratio = 2.65, p = .028). Tumor location (atria, ventricles, septum) was not predictive of mortality.

CONCLUSION

Benign atrial and ventricular tumors are uncommon, but disproportionately impact female patients, with female sex being an independent predictor of 30-day mortality. Root-cause analysis is necessary to determine the ultimate cause of this disparity.

Characteristics, management, and outcomes among admissions for primary cardiac tumors: Results from the National Inpatient Sample

INTRODUCTION

Primary cardiac tumors (PCT) are rare, and their contemporary outcomes are not well characterized in the literature. We assessed temporal trends in patient characteristics and management of admissions for PCT in US hospitals.

METHODS

Admissions with the principal diagnoses of a PCT (benign neoplasm of heart: ICD-9 212.7, ICD-10 D15.1; malignant neoplasm of heart: ICD-9 164.1, ICD-10 C38.0) between 2006 and 2017 were extracted from the National Inpatient Sample. Trends in demographics and clinical profiles were evaluated. We conducted descriptive analyses on the cohort and compared outcomes between those managed medically and surgically.

RESULTS

Between 2006 and 2017, 19,111 admissions had the primary diagnosis of a PCT. Of these, 91.1% were benign. Admissions were mostly female (65.0%), caucasian (72.0%), and aged more than 50 years (76.0%). The annual admission rate for PCT was similar from 2006 to 2017 (p trend > .05) and associated with congestive heart failure, diabetes, renal failure, and valvular lesions. PCTs were managed surgically in 12,811 (67.0%) of overall cases, 70.8% for benign and 28.3% for malignant tumors. Overall, the in-hospital mortality rate was 2.3%. Medically managed cases reported a 2.5% higher mortality (p < .001) than those surgically managed. Admissions with malignant tumors were more likely to expire during hospitalization than those with benign tumors (odds ratio, 9.75; 95% confidence interval 6.34-14.99; p < .001).

CONCLUSION

Admissions for primary cardiac tumors were primarily women or in their fifth or sixth decade of life. Surgical intervention is more commonly practiced and is associated with better in-hospital survival.

Evaluation of the potential predictors of embolism in patients with left atrial myxoma

INTRODUCTION

Cardiac myxomas are the most common primary intracardiac tumors. Although myxomas are histologically benign, they are potentially dangerous due to potential risk of systemic and cerebral embolism. In this study, we aimed to investigate the potential predictors of embolism in patients with left atrial myxoma.

METHODS

This single-center retrospective study enrolled 93 patients (mean age: 52.9 ± 15.3 years, female: 70 [75.3%]) with left atrial myxomas between 2014 and 2018. The patients were classified into two groups (embolic vs nonembolic) to investigate possible predictors of embolism. Demographic, laboratory, and echocardiographic parameters were recorded into a dataset and compared between patients with and without embolism.

RESULTS

The study population was composed of 13 (14%) patients in embolic (11 cerebrovascular and 2 peripheral) and 80 (86%) patients in nonembolic group. Demographic and laboratory parameters were similar between the groups. Tumor sizes were significantly higher in the embolic group than in the nonembolic group (5.59 ± 1.08 vs 4.29 ± 0.61; P = 0.001). By multivariate analysis, increased tumor size, increased left atrial diameter, and the presence of atrial fibrillation and irregular tumor surface were identified as independent predictors of embolism. In ROC curve analyses, tumor size above 4.6 cm predicted embolism with a sensitivity of 77% and a specificity of 73% (AUC: 0.858; 95% CI: 0.752-0.964; P < 0.001).

CONCLUSION

The presence of atrial fibrillation, irregular tumor surface, increased tumor size, and increased left atrial diameter is associated with increased risk of embolism in patients with left atrial myxoma. Early surgery should be scheduled for such patients due to increased potential for embolism.

Outcomes of Patients with Newly Diagnosed Cardiac Myxoma: A Retrospective Multicentric Study

The patient database at the First Department of Internal Medicine in Martin, the Central Slovak Institute for Cardiac and Vascular Diseases in Banska Bystrica, and the National Slovak Institute of Cardiovascular Diseases in Bratislava was searched to identify patients with benign tumors of the heart seen during the 5-year period between 2011 and 2016. Forty-one patients with primary cardiac myxomas were identified and their medical records were reviewed for details pertaining to presenting symptoms, staging modalities, treatment approaches, and outcomes. Most of the studied patients were diagnosed with echocardiography (n = 35, 85%). The occurrence of the tumor was higher in the female population (n = 25, 61%). The most common presenting symptoms were dyspnoea (n = 17, 42%), chest pain (n = 3, 7%), or pain and paraesthesia of the limbs (n = 2, 5%). Acute embolic event due to embolization of tumor fragments resulted in cerebral stroke (n = 5, 12%). All patients were treated by resection. Only one comorbid patient died due to multiple-organ dysfunction syndrome two weeks after the resection. The most common postoperative complication was bleeding (n = 2, 5%) and infection (n = 2, 5%). The early diagnosis and appropriate treatment are often curative, with very low risk of recurrence. Postoperative survival is high.

Cardiac tumors: echo assessment

Cardiac tumors are exceedingly rare (0.001–0.03% in most autopsy series). They can be present anywhere within the heart and can be attached to any surface or be embedded in the myocardium or pericardial space. Signs and symptoms are nonspecific and highly variable related to the localization, size and composition of the cardiac mass. Echocardiography, typically performed for another indication, may be the first imaging modality alerting the clinician to the presence of a cardiac mass. Although echocardiography cannot give the histopathology, certain imaging features and adjunctive tools such as contrast imaging may aid in the differential diagnosis as do the adjunctive clinical data and the following principles: (1) thrombus or vegetations are the most likely etiology, (2) cardiac tumors are mostly secondary and (3) primary cardiac tumors are mostly benign. Although the finding of a cardiac mass on echocardiography may generate confusion, a stepwise approach may serve well practically. Herein, we will review such an approach and the role of echocardiography in the assessment of cardiac masses.

A rare case of right ventricular myxoma causing recurrent stroke

We present a 62-year-old lady admitted in our hospital with two episodes of acute ischemic stroke about 2 weeks apart. She was evaluated for acute ischemic stroke and was thrombolysed for recent stroke in right MCA territory first time. On further evaluation, she was found to have a RVOT mass. A transthoracic and transesophageal echocardiogram revealed a PFO and a large, 5.1 cm × 2.3 cm, ovoid, well circumscribed, echogenic mass in the right ventricle outflow tract attached by small pedicle to the ventricular side of anterior tricuspid leaflet, partly obstructing the right ventricular outflow tract and protruding through the pulmonic valve during systole. She was scheduled for surgery (right ventricular mass excision and PFO closure) after 3 weeks due to the risk of secondary hemorrhage in the infarcted area following thrombolysis and anticoagulation and so was discharged with medications after full neurologic recovery after about a week of hospital stay.

She was readmitted 7 days after discharge, before the scheduled date of surgery with history of weakness of right upper limb, slurred speech and mild breathing difficulty lasting for about 20 min following which she improved slowly (transient ischemic attack). The tumor was completely removed with the stalk using cardiopulmonary bypass support. The histopathological findings confirmed the diagnosis of myxoma.

Risk prediction for emboli and recurrence of primary cardiac myxomas after resection

BACKGROUND

Risk factors for embolism and recurrence of primary cardiac myxoma are not well established. This study aimed to assess the risk factors for embolism and recurrence of cardiac myxoma, as well as the survival of the patients.

METHODS

The medical records of 207 consecutive patients treated for primary cardiac myxoma between September 1988 and October 2014 were retrospectively analyzed. All diagnoses were pathologically confirmed. Data were collected to identify the risk factors influencing the prognosis.

RESULTS

Mean age at surgery was 44.2 ± 15.8 years. Operative mortality (within 30 days of the surgery) occurred in seven patients. Mean follow-up was 9.35 ± 6.55 years. Embolism occurred in 32 (15.5 %) patients before surgery. Multivariate analysis indicated that small (≤ 4.5 cm) myxoma (OR = 5.14; 95 % CI, 2.30-11.94; P < 0.0001) and soft, gelatinous myxoma (OR = 5.84; 95 % CI, 1.91-25.61; P = 0.001) were independently associated with the occurrence of embolism. Ten patients experienced recurrences. After excluding the patients who died within 30 days of surgery, survival was 92.7 % at 10 years. Age, sex, tumor size, cardiopulmonary bypass duration, aortic cross clamp duration, tumor appearance, and pre-operative embolism were not associated with early mortality. Multivariate analysis showed that multicentric myxomas were independently associated with recurrence (OR = 9.45, 95 % CI, 2.15-41.3, P = 0.004).

CONCLUSIONS

The surgical resection of primary cardiac myxoma is associated with excellent long-term survival. Tumors ≤ 4.5 cm and soft tumors were independent risk factors for embolism. Multicentric cardiac myxoma was an independent risk factors for recurrence of myxoma.

Surgical treatment for primary mitral valve tumor: a 25-year single-center experience

OBJECTIVE

Primary mitral valve (MV) tumor is a rare lesion, and to date, there have been few larger surgical series of MV tumors. We retrospectively analyzed 11 cases of primary MV tumors regarding clinical and pathological features, surgical procedure and long-term outcomes.

METHODS

From November 1983 to December 2008, we operated on 11 patients (age 36.3 ± 17.7 years, weight 55.4 ± 11.2 kg) with primary MV tumors. Symptoms were cardiac in 8 cases (72.7%) and neurologic in 3 (26.3%). Surgical procedures included en bloc excision and MV repair in 8 cases and tumor resection and MV replacement in 3. No radiotherapy or chemotherapy was given to patients with malignant tumors.

RESULTS

Pathological diagnosis was papillary fibroelastoma in 3 cases, myxoma in 3, lymphangioma in 1, lipoma in 1, hemangioma in 1 and sarcoma in 2. No early deaths or complications occurred. Late death occurred in 2 patients with sarcoma 1 year postoperatively. At the latest follow-up, with a maximum of 25 years (mean 10.6 ± 8.8), the 9 survivors were in New York Heart Association functional class I with normal MV function and no echocardiographic evidence of local recurrence.

CONCLUSIONS

The majority of primary MV tumors are benign. They can cause cardiac or neurologic symptoms and should be excised as soon as a diagnosis is made. For benign tumors, valve-sparing resection and valve repair are often possible with excellent long-term outcomes. The prognosis of malignant MV tumors is poor.

Minimally invasive video-assisted approach for left atrial myxoma resection

Minimally invasive surgery has become the standard approach for several cardiac diseases. We report in the present study our ten-year experience with endoscopic cardiac surgery for left atrial myxoma resection. Between January 1998 and January 2008, 14 patients (median age: 61 years) underwent surgery for left atrial myxoma resection at our institution. The Heartport access system and the video-assistance were systematically employed to provide excellent vision and facilitate surgery. The aortic clamping was obtained with an 'EndoClamp' in 11 cases (using a central or peripheral endoaortic balloon, depending on the site of the arterial cannulation) or transthoracically with the Portaclamp system in two cases and the Chitwood clamp in one case. The average time needed for cross-clamping was 49+/-29 min, with a mean cardiopulmonary bypass (CPB) time of 88+/-57 min. There were no early or late hospital deaths. Mean intensive care unit and hospital stay were three and eight days, respectively. The mean follow-up time was 64 months and there was no evidence of residual or recurrent tumor. There were two late deaths due to acute ischemic stroke. Minimally invasive video-assisted surgery for left atrial myxoma resection is a safe, reproducible and cosmetic operation and can be considered an effective oncologic approach as an alternative to standard sternotomy.

Investigation of a myxoma in the right ventricular outflow tract

We describe an atypical myxoma in the right ventricular outflow tract of a 12-year old girl. After identification using echocardiography, we assessed its precise location and attachments by magnetic resonance imaging. Subsequent to surgical removal, histology confirmed the myxomatous nature of the tumour.

Survival after resection of primary cardiac tumors: a 48-year experience

BACKGROUND

Primary cardiac tumors are rare but have the potential to cause significant morbidity if not treated in an appropriate and timely manner. To date, however, there have been no studies examining survival characteristics of patients who undergo surgical resection.

METHODS AND RESULTS

From 1957 to 2006, 323 consecutive patients underwent surgical resection of primary cardiac tumors; 163 (50%) with myxomas, 83 (26%) with papillary fibroelastomas, 18 (6%) with fibromas, 12 (4%) with lipomas, 28 (9%) with other benign primary cardiac tumors, and 19 (6%) with primary malignant tumors. Operative (30 day) mortality was 2% (n=6). Univariate analysis indicated that patients who underwent resection of fibromas and myxomas had superior survival characteristics in comparison to the remainder of tumor variants; these results were consistent after adjusting for age at surgery, year of surgery, and cardiovascular risk factors. Based on actuarial characteristics of the 2002 U.S. population, patients who underwent myxoma resection had survival characteristics that were not significantly different from that of an age and gender matched population (SMR 1.11, P=0.57) whereas those who underwent resection of fibromas (SMR 11.17, P=0.002), papillary fibroelastomas (SMR 3.17, P=0.0003), lipomas (SMR 5.0, P=0.0003), other benign tumors (SMR 4.63, P=0.003), and malignant tumors (SMR 101, P<0.0001) had significantly poorer survival characteristics. Furthermore, malignant tumors in younger patients were highly fatal (HR 0.899, P<0.0001). Although the most significant predictor of mortality was tumor histology, survival was also influenced the by the duration of CPB and NYHA III/IV; the impact of these risk factors varied with time. The cumulative incidence of myxoma recurrence was 13% and occurred in a younger population (42 versus 57 years, P=0.003) with the risk of recurrence decreased after 4 years.

CONCLUSIONS

Surgical resection of primary cardiac tumors is associated with excellent long-term survival; patients with cardiac myxomas have survival characteristics that are not significantly different from that of a general population. Predictors of mortality are primarily related to tumor histology but also include clinical characteristics such as symptomatology and duration of CPB.

Cardiac tumours in children

Cardiac tumours are benign or malignant neoplasms arising primarily in the inner lining, muscle layer, or the surrounding pericardium of the heart. They can be primary or metastatic. Primary cardiac tumours are rare in paediatric practice with a prevalence of 0.0017 to 0.28 in autopsy series. In contrast, the incidence of cardiac tumours during foetal life has been reported to be approximately 0.14%. The vast majority of primary cardiac tumours in children are benign, whilst approximately 10% are malignant. Secondary malignant tumours are 10-20 times more prevalent than primary malignant tumours. Rhabdomyoma is the most common cardiac tumour during foetal life and childhood. It accounts for more than 60% of all primary cardiac tumours. The frequency and type of cardiac tumours in adults differ from those in children with 75% being benign and 25% being malignant. Myxomas are the most common primary tumours in adults constituting 40% of benign tumours. Sarcomas make up 75% of malignant cardiac masses. Echocardiography, Computing Tomography (CT) and Magnetic Resonance Imaging (MRI) of the heart are the main non-invasive diagnostic tools. Cardiac catheterisation is seldom necessary. Tumour biopsy with histological assessment remains the gold standard for confirmation of the diagnosis. Surgical resection of primary cardiac tumours should be considered to relieve symptoms and mechanical obstruction to blood flow. The outcome of surgical resection in symptomatic, non-myxomatous benign cardiac tumours is favourable. Patients with primary cardiac malignancies may benefit from palliative surgery but this approach should not be recommended for patients with metastatic cardiac tumours. Surgery, chemotherapy and radiotherapy may prolong survival. The prognosis for malignant primary cardiac tumours is generally extremely poor.

Concomitant intramyocardial and epicardial vasculitis in an autopsied heart allograft for cardiac rhabdomyosarcoma

Primary cardiac tumours are rare, with only one quarter of the patients being malignant. The vast majority of malignant neoplasms of the heart are sarcomas. We describe a patient of primary cardiac rhabdomyosarcoma presented as coronary artery disease and recurrent myocardial infarction. Histopathologic finding of the excised native heart revealed a high grade pleomorphic rhabdomyosarcoma in the myoepicardial portion of the anterior wall with rupture. The accompanying unusual feature was myocardial infarction because of tumour emboli of the left anterior descending and left circumflex coronary arteries. After transplantation, the patient developed mild to moderate acute cellular rejection of the transplanted heart on post-transplantation day 1, 8, and 44, respectively. Unfortunately, he expired on the post-transplantation day 47 because of acute rejection, presenting as concomitant intramyocardial and epicardial lymphocytic vasculitis and multifocal myocardial ischaemia. We found that this uncommon medial lymphocytic vasculitis lesion was mediated by T cells and also by antibody directly against smooth muscle cells of small arteries. The consequence of such immune response would be compromised myocardial oxygenation resulting in allograft failure.

Cardiomyoplasty: ventricular reconstruction after tumor resection

OBJECTIVE

Although cardiac transplantation has been performed for complete removal of ventricular tumors, complete surgical resection with ventricular reconstruction is desirable. Thus patients with benign tumors would probably be cured, and those with malignant tumors would have a better prognosis. In this study extensive and complete surgical resection of ventricular tumors is followed by anatomic and functional ventricular reconstruction with a dynamic cardiomyoplasty procedure.

METHODS

Seven patients (mean age, 32.7 years) underwent complete resection of ventricular tumors. Histologic types were distributed as follows: fibroma in 2 patients and sarcoma, lymphosarcoma, hemangioma, lipoma, and metastatic angiosarcoma, respectively, in the remaining 5 patients. Six of the patients were considered candidates for heart transplantation because of the extent of tumor invasion. Surgery consisted of 4 steps: (1) tumor resection; (2) coronary artery resection (when invaded by the tumor) and coronary artery bypass grafting; (3) valvular reconstruction (when possible) or replacement; and (4) ventricular wall reconstruction with a pericardial patch for closure of the ventricular defect (neoendocardium) covered by the electrostimulated latissimus dorsi muscle flap (neomyocardium).

RESULTS

All patients survived surgical intervention, but 2 late postoperative deaths are reported. Among the surviving patients, early complications played a major role in their postoperative course and consisted of arrhythmias, atrioventricular block necessitating a dual-chamber pulse generator, respiratory insufficiency, and heart failure. Two patients were assisted postoperatively with an intra-aortic balloon pump. On postoperative follow-up (mean, 72.4 +/- 8.5 months), an improvement in the patients' functional status was observed. Patients moved from a mean New York Heart Association functional class of 2.8 to a mean functional class of 1.2.

CONCLUSIONS

The excellent long-term evolution without recurrence, ventricular dysfunction, and/or thromboembolic complications implies that cardiomyoplasty could be recommended as an alternative to heart transplantation for the therapy of large ventricular tumors.

Therapy for primary cardiac tumors: is there a role for heart transplantation?

Primary cardiac tumors are rare clinical entities. Benign tumors are often amenable to surgical excision, whereas malignant tumors are seldom resectable. The literature has reported that 28 patients have undergone orthotopic heart transplantation for inoperable primary cardiac tumors. The results of these transplants are presented in this article. Of the 28 patients who underwent orthotopic heart transplantation for primary cardiac neoplasms, 7 patients had benign histology (fibroma-5, rhabdomyoma-1, and pheochromocytoma-1) and 21 patients had malignant histology (sarcoma-15, malignant fibrohistiocytoma-3, and lymphoma-3). Mean survival in the patients with benign histology was 46 months, and the mean survival in the patients with malignant histology was 12 months. However, there were seven patients with malignant histology who had survived for a mean of 27 months without evidence of recurrent disease. An awareness by clinicians of the presenting clinical picture of these tumors is warranted in view of the potential for cure by resection or transplantation. Patients with benign primary cardiac tumors appear to benefit from the complete resection afforded by cardiectomy and transplantation. The role of transplantation for patients with malignant tumors remains unclear. Further experience and continued follow-up of these patients is necessary to ascertain the role of cardiac transplantation, radiation, and chemotherapy in the management of patients with primary tumors of the heart.

Primary cardiac tumors: early and late results of surgical treatment in 91 patients

BACKGROUND

Between March 1980 and September 1997, 91 patients underwent evaluation and treatment for primary cardiac neoplasms.

METHODS

Tumors were grouped into three categories: atrial myxomas, benign nonmyxomas, and malignant tumors. Survivors were contacted; no one was lost to follow-up. The mean follow-up for this series is 7 +/- 5 years.

RESULTS

Eighty-three patients were diagnosed with atrial myxomas (Male/Female: 29/54), average age 55 +/- 13 years. The hospital mortality was 3.6% (3/83), the late mortality was 6.5% (5/80). No recurrent myxomas have been identified clinically or by echocardiography in any patient. Three patients were diagnosed with benign nonmyxoma tumors. (Male/Female: 2/1), average age 64 +/- 8 years. There were no perioperative deaths and 1 patient died 4 years postoperatively from fibroma, with no linked causes. No recurrent tumors have been identified. Five patients were diagnosed with malignant tumors. (M/F: 1/4), average age 53 +/- 16 years. The hospital mortality was 20% (1/5); in 3 patients a redo-operation was necessary after 8, 11, and 12 months because of tumor recurrence. All patients died within 3 years of the first operation (mean 13 +/- 14 months).

CONCLUSIONS

Surgical resection, when possible, is the treatment of choice for all primary cardiac tumors. Patients with benign tumors are probably cured by resection and in our experience there was no known tumor recurrence. Effective palliation is possible with resection of malignant tumors, but more effective adjuvant therapy will be necessary to improve long-term prognosis.

Treatment of life-threatening huge atrial myxoma: report of two cases

We herein report two patients with left atrial myxoma who needed an emergency operation. Case 1 was a 48-year-old woman who was injured in a traffic accident and underwent an operation for a right leg fracture. Just after the operation she developed cardiac and respiratory arrest with complaints of chest pain. She was successfully resuscitated and diagnosed to have a left atrial myxoma by echocardiography. Emergency surgery was performed and a giant left atrial myxoma was thus removed from the atrial septum. Case 2 was a 54-year-old housewife who was transferred to our department under the diagnosis of a left atrial myxoma by echocardiography. She complained of dyspnea and chest discomfort. By angiography, the tumor was seen to be partially incarcerated at the diastolic phase. A huge myxoma was removed from the atrial septum which was secured by a patch closure. Cardiac echocardiography can help rule out left atrial myxoma if it is highly suspected. As early surgical mortality is low and the long-term results are good, we strongly believe that patients with cardiac myxoma should be operated on as early as possible, once a diagnosis is made.

[Cardiac hemangioma of the right ventricle--report of a case]

A 74-year-old male was admitted to our hospital with a diagnosis of intra-cardiac tumor on echochardiography, CT, and MRI. The tumor was located on the free wall of the right ventricle and protruded into the outflow tract. The surgical excision of the tumor was performed under cardiopulmonary bypass. The size of the tumor was 5 x 5 x 4 cm. Histological examination disclosed cavenous hemangioma. The post opertive course was uneventful. This is the forth case reported in Japan and the fifteenth case in the world.

Cardiac myxomas: clinical and echocardiographic profile

We reviewed our clinical and echocardiographic experience in 70 consecutive patients with 73 cardiac myxomas, diagnosed over an 11 year period. There were 21 males and 49 females, ages ranged from 18 to 80 years. Only in 5.7% cases was the diagnosis of myxomas made clinically. 88.6% cases were initially diagnosed as having: mitral valve disease (70%), tricuspid valve disease (10%), ischemic heart disease (5.7%), cardiomyopathy (2.9%), and the remaining 5.7% were detected during family screening and follow-up. The mean duration of symptoms was 10.6 months. The commonest symptom was dyspnoea (80%), followed by constitutional symptoms (45.7%), embolization (30%), palpitation (25.7%), syncope (15.7%), pedal oedema (15.7%) and pain chest (12.9%). The sites of myxomas were as follows: left atrium, 58; right atrium, 9; and, biatrium, 3. All myxomas except 3 were attached to the interatrial septum. The site, size, shape, attachment, mobility, prolapse into ventricle, and surface characteristic of myxomas were accurately assessed by 2D-echocardiography and confirmed in all (65 of 70) who underwent surgery. When the morphological characteristic of myxomas were studied and correlated with clinical features large left atrial myxoma size was closely related with constitutional symptoms, congestive heart failure, with syncope and auscultatory findings suggestive of mitral valve disease, whereas smaller myxoma size and irregular surface were associated with embolization. Constitutional symptoms were only present in left atrial myxoma. Post-operative mean echocardiographic follow-up of 60 months showed no recurrence except in 2 with familial myxoma. We conclude that the majority of myxomas mimic many cardiovascular diseases and were detected in symptomatic patients, so a high index of clinical suspicion is important for its early and correct diagnosis. The size and appearance of the myxomas correlated with the presenting symptoms.

Primary cardiac tumors: forty years' experience with 71 patients

BACKGROUND

Primary cardiac tumors are infrequent, and few cardiac surgeons have extensive experience in treating them. The majority of the tumors are benign. As noninvasive diagnostic imaging of cardiac masses continues to improve, the number of these tumors that are seen by clinicians will increase. More of the malignant tumors may be curable if detected at an earlier stage.

METHODS

A retrospective review was conducted of all patients with primary cardiac tumors managed by a university teaching center over a period of 40 years, using hospital medical records and a Provincial cardiovascular surgery database.

RESULTS

Seventy-one patients (25 males and 46 females) with primary cardiac tumors were identified. Fifty-seven (80%) were benign masses and 14 (20%) were malignant masses. Twenty-eight percent of the tumors in men were malignant (7 of 25) compared with only 15% in women (7 of 46). Seventy-two percent of the masses were located in the left atrium. Forty-three percent of tumors in the right atrium were malignant (6 of 14) compared with only 14% in the left atrium (7 of 51). Complete resection was possible for 50 of 52 benign atrial tumors (96%) but for only 5 of 14 malignant tumors (36%). There was one perioperative death (1.4%). Three patients had no surgery because of their poor medical condition. Two of the patients with unresectable malignant tumors were still alive at last follow-up. The remaining 12 patients with malignancy have all died of their disease.

CONCLUSIONS

Primary cardiac tumors are uncommon. Most patients present with symptoms of congestive heart failure. The second most common presenting symptom is embolization. Improvement in noninvasive diagnostic technology has increased the number of patients identified with a primary cardiac tumor and has also increased the number referred for surgical resection. The majority of left atrial tumors were benign, whereas up to one-half of tumors found in the right atrium were malignant. A greater proportion of malignant primary tumors were found in men than in women. Malignant cardiac tumors tend to be diagnosed after they have become extensive and the patients already have a very grave prognosis.

Right ventricular myxoma: report of a case

We herein report a 36-year-old man who underwent surgical resection for myxoma. Preoperative two-dimensional echocardiography demonstrated a mass in the right ventricle. Intraoperatively, the tumor was found to derive from an anterior papillary muscle of the tricuspid valve. The tumor was successfully excised and the tricuspid valve was repaired with chordoplasty and annuloplasty. A histopathological examination revealed myxoma and a 2-year follow-up has shown no evidence of recurrence or tricuspid valve regurgitation.

Malignant Fibrous Histiocytoma of the Left Atrium

A 25-year-old female presented with symptoms resembling those of critical mitral stenosis. Echocardiography revealed a left atrial mass without a stalk, which was suspected to be a left atrial myxoma. An irregular soft friable mass was found at surgery. It measured 10 × 8 cm, with finger-like extensions and occupied almost the entire left atrial cavity, extending into the three tributaries of the right pulmonary vein. Histopathology of the excised tumor including electron microscopy showed a pleomorphic cytology interlaced with bundles, areas of necrosis, and occasional bizarre tumor giant cells. Characteristic histiocytes containing lysosomes identified the tumor as malignant fibrous histiocytoma. A postoperative course of radiotherapy with a dose of 4,000 cGy/20 fractions was applied to the mediastinum. At follow-up 4 months later the patient was asymptomatic. This case is reported because of the extreme rarity of left atrial malignant fibrous histiocytoma.

Cardiac Hemangioma Arising in the Epicardium

A 32-year-old housewife was treated for recurrent pericardial effusion with repeated pericardiocentesis and pleuropericardial window formation after a diagnosis of tuberculous pericarditis. The biopsied pericardium revealed nonspecific inflammation. In spite of continuing antituberculosis medication, she did not improve and the pericardial effusion increased with emerging signs of progressive right heart failure. A pericardiectomy was performed and multiple masses with a cobblestone appearance were found on the entire epicardium and the great vessels. The partially excised masses showed mesothelial hyperplasia and capillary hemangioma. The pericardial effusion continued and radiation therapy (2,000 cGy/2 weeks) was given with corticosteroid to control immune thrombocytopenic purpura. On the 87th postoperative day, a left posterolateral thoracotomy was performed to remove a large pleural hematoma which was compressing the left atrium and the left ventricle. We found extensive spread of the hemangioma into the pleural cavity along the intercostal vessels. The patient died 3 days later from massive uncontrollable hemorrhage.

INTRACARDIAC TUMOURS - EXPERIENCE WITH 12 CASES

Twelve cases of intracardiac tumours operated during the period 1975 to 1994 are presented. There were 8 males and 4 females in the age range of 18 years to 64 years. Tumours were located in the left atrium in 10 patients and in the right atrium in 2 patients. Standard cardiopulmonary techniques were followed. The right atrial tumours were approached through a right atrial incision while the left atrial tumours were approached through a bi-atrial trans-septal approach. One patient underwent a perineal urethrolithotomy for an impacted urethral calculus at the same sitting. Eleven of the tumour masses excised were myxomas confirmed on histopathology. The last patient, operated for synovial sarcoma of the left knee 2 years before, presented with a metastatic tumour mass in the left atrium. No deaths occurred in the series.

Cardiac valvular chondroma

The case of a 36-year-old woman with a tricuspid valvular tumor is presented. The lesion was successfully resected through the right atrium. Histologic examination showed a chondroma arising in a cardiac valve.

Cardiac hemangiomas

Cardiac hemangiomas are rare benign vascular tumors of the heart. To date, 23 cases have been reported. Symptoms are usually due to compression of cardiac structures or obstruction of outflow tracts. Echocardiography usually directs the diagnosis toward a cardiac mass. Enhanced-contrast computed tomographic scan or magnetic resonance imaging establishes the diagnosis of hypervascularized cardiac tumor. Coronary arteriography establishes the diagnosis by showing the characteristic tumor blush. Surgical resection is done using cardiopulmonary bypass. Long-term outcome is favorable.

Atrial myxoma: national incidence, diagnosis and surgical management

Despite being the most common benign intracardiac tumour with an excellent prognosis after surgical excision the incidence of atrial myxoma (except at autopsy) is unknown. We reviewed all patients admitted to the National Cardiac Surgery Unit (n = 26) with an atrial myxoma over a fifteen year period (1977-1991) to compile national incidence data and assess pre-operative diagnosis, management, surgical technique, and outcome. Preoperative symptoms were: congestive cardiac failure (12 patients), embolism (8 patients), constitutional (3 patients), asymptomatic (2 patients) and tachyarrhythmia (1 patient). The diagnosis was confirmed by 2D echocardiography alone in thirteen patients and by a combination of echocardiography and angiography in thirteen patients. At operation the site of the tumour was left atrial in 24 patients and bi-atrial in two patients. All cases were confirmed by histology. All patients made a good post-operative recovery, although one patient survived a pulmonary embolus and one patient developed a deep venous thrombosis. There has been one late death (five months after surgery) from a cerebrovascular accident. Serial echocardiography has revealed one recurrence to date (8 years after surgery). The surgical incidence of these tumours in the Republic of Ireland over the study period was 0.5 atrial myxomas/million population/year. Although rare atrial myxomas are the most important cardiac tumours to diagnose as the results from surgery are excellent.

Cardiac tumors: clinical experience and surgical results in 74 patients

A series of 75 cardiac tumors in 74 patients were operated on at La Pitie Hospital between 1972 and 1989. There were 73 primary and 2 metastatic tumors. Among the benign neoplasms, 58 were myxomas; seven of the nine malignant tumors were primary heart tumors. The mean age of the patients was 48 years (range, 9 to 75 years); 46 patients were female and 28 male. Fifty-seven percent of the patients had congestive heart failure, 13% had chest pain, 17% had neurological symptoms, and only 1 patient was totally asymptomatic. The cardiac tumors were incidental findings in 3 patients. Complete resection was carried out in 66 benign lesions and only four of the malignant tumors. All patients survived operation, although 4 died in the early postoperative period. Long-term results were excellent in patients with benign lesions, and no recurrences were found. In patients with malignant tumors, surgical procedures were only palliative and aimed at prolonging life; hence, prognosis remained unchanged.

Primary cardiac sarcomas

In marked contrast to benign cardiac tumors, primary cardiac sarcomas occur infrequently. Moreover, there is no uniform approach to treating such patients, and the benefits of postoperative chemotherapy are unclear. Between 1964 and 1989, 21 patients with primary cardiac sarcomas underwent surgical resection alone (n = 7), chemotherapy alone (n = 1), or combined operation and postoperative chemotherapy based on adriamycin (n = 13). Twenty-four operations were performed on 20 patients with relief of symptoms in all. Eleven patients had complete resection. Operative mortality was 8.3% (2/24). Histology and originating chamber(s) included angiosarcoma (n = 7; 6/7 in right atrium, 1 in left atrium), malignant fibrous histocytoma (7; all in left atrium), fibrosarcoma (2; 2/2 in left atrium), rhabdomyosarcoma (2; 1 in left atrium, 1 in right ventricle), leiomyosarcoma (2; 1 in left atrium, 1 in left ventricle); and one undifferentiated sarcoma (right atrium). Overall actuarial survival was 14% at 24 months after resection. Patients with complete resection had a median survival of 24 months compared with only 10 months in all other patients (p = 0.035). Postoperative chemotherapy did not enhance survival in patients with incomplete resection. At this time, aggressive and complete surgical resection seems to offer the best hope for palliation and survival in an otherwise fatal disease.

Surgical excision of intracardiac myxomas: a 20-year follow-up

Since November 1968, 54 patients have undergone excision of an intracardiac myxoma, which was located in the left atrium in 46 (85%), in the right atrium in 6 (11%), and in the right ventricle in 2 (4%). There were 35 female and 19 male patients with a mean age of 48 +/- 14 years (range, 7 to 68 years). Four patients were asymptomatic; the others were seen mostly with exertional dyspnea, palpitation, signs of systemic illness, and syncopal episodes. Before operation, embolic episodes occurred in 13 patients with a left atrial myxoma. There were two early (3.7%) and two late deaths (3.8). Actuarial survival at 20 years is 91% +/- 4%, and most of the current survivors are asymptomatic at a mean follow-up of 6.5 +/- 5 years (range, 0.2 year to 20 years). Noninvasive reevaluation was performed with echocardiographic studies in 44 patients and 24-hour electrocardiographic monitoring in 34. No instances of tumor recurrence were observed, and there was a low incidence of major supraventricular arrhythmias late postoperatively. We conclude that excision of intracardiac myxomas is curative and long-term survival is excellent. The transseptal approach provides adequate exposure and allows complete removal of the tumor regardless of its location.

Urgent indications for surgery in primary or secondary cardiac neoplasm

Ten patients underwent resection of primary or secondary cardiac tumor. Two-dimensional transthoracic echocardiography per se accurately located the endoluminal cardiac mass in nine patients, and transesophageal echocardiography demonstrated a right atrial tumor in the tenth case. The indications for urgent surgery included prior embolic events (3 cases), syncopal attacks (2) or echocardiographic evidence of a multilobulated mass (2 cases). The operative strategy was standardized for atrial tumors, but for malignant myocardial neoplasm both the anatomic site and the extent of tumor growth determined the surgical procedure. Histologic examination showed myxoma in seven cases, fibroma in one and metastases of malignant melanoma in two cases. The course after resection of endoluminal benign tumor was uneventful apart from transient atrial fibrillation in four cases. Follow-up echocardiography (after 4-28 months) showed no recurrent growth. In both cases of intracardiac metastases there was recurrence within 6 to 8 months after resection of the growth.

Cardiac neoplasms: current diagnosis, pathology, and therapy

Cardiac neoplasms remain enigmatic because of their rarity and protean clinical manifestations. Although surgery for benign cardiac neoplasms seems straightforward, certain difficulties in diagnosis and extirpation often exist. Newer diagnostic modalities including intraoperative transesophageal echocardiography seem promising and may provide better planning for the surgeon. Moreover, cardiac transplantation has provided relief for some patients with irresectable benign neoplasms. As ventricular arrhythmias may emanate from benign tumors, electrophysiologically guided extirpation may provide helpful control. Malignant cardiac tumors remain the true challenge, whether primary or metastatic, as little surgical or medical progress has resulted. This review examines nearly all diagnostic, pathological, histologic, and therapeutic aspects of benign and malignant cardiac tumors. Moreover, the various surgical approaches necessary for removal of resectable neoplasms are detailed.

A report and review of recurrent left atrial myxoma: not always such 'a benign tumor'

We report a patient whose left atrial myxoma recurred three times and review 28 other reports of recurrent myxoma. Inadequate resection and multifocal growth appear to be two separate causes for recurrence.

Mesenteric artery embolization by an unsuspected aortic tumor: diagnostic evaluation and operative management

Malignant tumor embolus recovered at the time of superior mesenteric artery embolectomy is an uncommon experience. A report of such a case is presented and the literature is reviewed. In this clinical setting, guidelines for further diagnostic evaluation are not well defined. We suggest an algorithm for the evaluation and management of these patients. In the near future, use of intraoperative angioscopy and the intravascular laser to eradicate the tumor may represent the optimal method of treatment.

Primary malignant pericardial mesothelioma mimicking left atrial myxoma. Case report

In a 32-year-old man with clinical and echocardiographic signs mimicking left atrial myxoma, thoracotomy revealed a highly malignant pericardial mesothelioma with an intraatrial pendulous extension and haemorrhagic pericardial exudate. CT scanning of the thorax is useful when an intracavitary cardiac mass is associated with pericardial exudate and/or with suspected extracavitary involvement.