Cardiomyoplasty: ventricular reconstruction after tumor resection

Case Report: Mitral valve obstruction by metastatic malignant phyllodes tumor

Cardiac metastases are rare. Herein, we report a case of a 37-year-old female patient with a history of borderline breast phyllodes tumor (PT) treated by surgery, admitted to our department for concomitant cardiac and pulmonary metastases of malignant PT. Cardiac metastasis occurred through direct extension from pulmonary metastasis to the left atrium via the right inferior pulmonary vein, causing severe mitral valve obstruction. Although the total surgical removal of metastases, the patient had a huge relapse of the mediastinal metastasis resulting in her death.

Surgical treatment of primary cardiac tumors in the contemporary era: A single-centre analysis

Background

Primary cardiac tumors (PCT) are rare lesions but have the potential to cause significant morbidity if not timely treated. We reviewed our single‐center experience in the surgical treatment of PCT with a focus on the long‐term outcome.

Methods

From 2001 to 2020, 57 consecutive patients underwent surgical resection of PCT at our Institution. Data including the demographic characteristics, tumor histology, surgical procedure, and postoperative outcomes were collected and analyzed.

Results

Mean age at presentation was 63.6 ± 11.2 years, and 33 (57.9%) of the patients were female. A total of 55 (96.5%) subjects were diagnosed with benign cardiac tumor, while the remaining had malignant tumors. The most common histopathological type was myxoma. All patients survived to hospital discharge. Main postoperative complications were: acute kidney injury (n = 3), sepsis (n = 3), and stroke (n = 2). Mean follow‐up time was 9 ± 5.9 years. Long‐term mortality was 22.8% (13/57). No tumor recurrence was observed among survivors. There was a significant relationship between mortality and pathological characteristics of the tumor, and myxomas had higher survival rates.

Conclusion

Surgical treatment of PCT is a safe and highly effective strategy associated with excellent short‐term outcomes. Long‐term survival remains poor for primary malignant tumors of the heart.

Elusive Cardiac Angiosarcoma in a Young Pregnant Female: Rare Presentation With Fatal Outcome

Heart tumors are rare occurrences. They can present diagnostic challenges and severe complications especially in pregnant women. We report a rare case of angiosarcoma (AS) cordis of the right atrium in a young healthy pregnant female. Her diagnosis remained elusive for some time until development of advanced disease symptomatology. The diagnosis was unfortunately clinched when her tumor grew to be detected by imaging modalities. An emergency cesarean section was performed delivering a healthy baby. The patient was aggressively treated with chemotherapy to no avail. She passed away 2 months after her diagnosis was established. Only few cases of the occurrence of aggressive cardiac AS and human pregnancy are documented. The course of this disastrous combination is usually marked by severe complications, difficult therapeutic options and ultimately fast demise. Physicians need to be more aware of such diagnosis and diligently try to diagnose it as early as possible.

Cardiac tumours in infancy

Cardiac tumours in infancy are rare and are mostly benign with rhabdomyomas, fibromas and teratomas accounting for the majority. The presentation depends on size and location of the mass as they tend to cause cavity obstruction or arrhythmias. Most rhabdomyomas tend to regress spontaneously but fibromas and teratomas generally require surgical intervention for severe haemodynamic or arrhythmic complications. Other relatively rare cardiac tumours too are discussed along with an Indian perspective.

Intracardiac metastasis of esophageal squamous cell carcinoma -report of a case-

We report a case of a 48-year-old man with a history of violent coughing fits and general fatigue underwent urgent surgery for cardiac tamponade, and who was later diagnosed with metastatic intracardiac squamous cell carcinoma of the esophagus. After admittance to Munakata Suikokai General Hospital, Fukuoka, Japan, echocardiography showed extensive pleural and pericardial effusion and a mass, 4 by 2 cm, with a solid echo pattern in the right ventricular cavity. The working diagnosis was primary malignant cardiac tumor of unknown origin with multiple metastases. To prevent sudden death due to obliteration of the outflow tract of the right ventricle, we performed urgent surgery for cardiac tamponade. Histological examination of the resected tumor revealed squamous cell carcinoma. Fiberoptic esophagoscopy showed hypertrophy of the esophageal wall and a submucosal tumor extending throughout the esophagus. Microscopic examination of the esophagus biopsy specimen showed moderately differentiated squamous cell carcinoma, the histology of which was similar to that of the resected tumor and cytology of pericardial effusion. The patient recovered and was able to return home for a few days; however, he was readmitted, and despite maximal supportive therapy, he died one month after the operation.

Ventricular mass: a clinical and surgical conundrum

Cardiac tumours are rare in occurrence. The authors report a patient who presented with a history of recurrent transient ischemic attacks and cerebrovascular accidents. During rehabilitation he was incidentally diagnosed with a large left ventricular mass which was excised successfully with good clinical outcome. On histopathology it was a papillary fibroelastoma.

Pulmonary artery obstruction due to a metastatic malignant phyllodes tumor of the breast

A 65-year-old woman with a 9-year surgical history of a left breast phyllodes tumor was admitted with progressive chest pain on effort. Computed tomography showed severe stenosis of the main pulmonary artery, with the mass originating from the ventricular septum. We planned to resect the tumor the next day. However, the next morning a pulmonary artery embolism occurred, and she developed dyspnea and lost consciousness. After carrying out cardiopulmonary resuscitation, we performed a life-saving operation. We successfully resected the huge tumor as far as possible from the right ventricle via a right atrial (RA)-tomy. However, her consciousness did not improve to better than Glasgow Coma Scale grade 7. She died from suffocation caused by metastasis invading her airway despite undergoing tracheotomy on the 77 th postoperative day.

Cardiac bioassist: results of the French multicenter cardiomyoplasty study

The French multicenter experience (6 centers) of dynamic cardiomyoplasty was analyzed for long-term survival and functional outcome, the most important endpoints in congestive heart failure therapy. Cardiomyoplasty was performed in 212 patients with symptoms of chronic heart failure despite maximal pharmacological therapy. The etiology was ischemic (48%), idiopathic (45%) or other (7%). Cardiomyoplasty was performed using the latissimus dorsi muscle which was electrostimulated after surgery. During follow-up, 88% of patients improved clinically. Hospital death occurred in 29 (14%) patients and was related to the severity of preoperative heart failure symptoms. Late mortality occurred in 99 patients due to heart failure (44%), sudden death (37%), or noncardiac causes (18%). Combined dynamic cardiomyoplasty and implantation of a cardiac rhythm management system was safely achieved in 22 patients, and 26 underwent heart transplantation for recurrent heart failure. Long-term functional improvements were observed in most patients, and the best outcome was achieved in those with isolated right ventricular failure. Dynamic cardiomyoplasty can be considered as a destination therapy or a mid- to long-term biological bridge to heart transplantation.

Primary Right Atrial Angiosarcoma

A rare case of right atrial angiosarcoma is described in a 55-year-old man who was admitted with acute chest pain. Electrocardiography, cardiac enzymes, and chest radiography were negative. His pain settled and he was discharged, but readmitted 15 days later with clinical features of cardiac tamponade. Computed tomography demonstrated a large pericardial effusion. Emergency surgery was performed to excise a right atrial tumor, which histology confirmed to be an angiosarcoma.

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 angiosarcoma: case report and review of the literature

Angiosarcoma of the heart, the most common primary malignant cardiac tumor in adults is known to carry a dismal prognosis. The diagnosis is often delayed because of the nonspecific clinical presentation. Symptoms are determined by the size and location of the tumor. Echocardiography has become the primary diagnostic technique because of its high degree of accuracy, noninvasiveness, and cost effectiveness. Complete surgical resection is required for improved survival. Conventional postoperative chemotherapy does not appear to modify the clinical course. We report a case of cardiac angiosarcoma with a large mural mass infiltrating the right atrial and ventricular walls and critically review the pertinent literature.

Surgical Treatment of a Huge Cavernous Hemangioma Surrounding the Right Coronary Artery

Hemangioma of the heart is an extremely rare benign cardiac tumor. A 61-year-old woman presented with a huge hemangioma on the right ventricle. The tumor was completely surrounding the right coronary artery. Under cardiopulmonary bypass, the right coronary artery was transected from the aortic sinus and the supplying arteries of the tumor were divided. The tumor was successfully resected, and the right coronary artery was reanastomosed to the aortic sinus.

Successful resection of a symptomatic right ventricular lipoma

We report the case of a 31-year-old woman with a 4-year history of recurrent palpitations, presenting with an increased frequency of paroxysms caused by ventricular tachycardias during pregnancy. A cardiac tumor of unknown origin infiltrating the right ventricle was diagnosed. Three weeks after prophylactic abrasion the tumor was totally excised with the use of cardiopulmonary bypass including restoration of the right ventricular wall and the tricuspid valve. Histology confirmed diagnosis of a benign cardiac lipoma. The postoperative course was uneventful and the patient was discharged 7 days after surgery. There was no episode of ventricular tachycardias during the 6-month follow-up.

Reevaluation of long-term outcomes of dynamic cardiomyoplasty

BACKGROUND

Palliative procedures have been proposed for treatment of dilated cardiomyopathies. This study analyzes long-term outcomes of 43 patients who underwent dynamic cardiomyoplasty.

METHODS

Patients were in New York Heart Association class III (n = 35) or IV (n = 8) before the procedure. Hospital mortality was 2.2%, and patients were followed for 44 +/- 33 months. Thirty-nine patients completed the skeletal muscle adaptation period, and the muscle flaps were stimulated to contract in concert with every cardiac beat (n = 27) or with every other beat (n = 12).

RESULTS

One-year event-free survival was 81.3% +/- 5.9%; 2-year, 65.1% +/- 7.2%; 5-year, 34.7% +/- 7.2%; and 9-year, 10.8% +/- 5.3%. Causes of late deaths were equally divided between progressive heart failure and arrhythmia-related events. Multivariable Cox proportional hazard regression identified that functional class IV, high pulmonary vascular resistance, and muscle flap stimulation synchronized to every cardiac beat were independent predictors of poor event-free survival. The same factors were associated with the occurrence of progressive heart failure, but none was a predictor of arrhythmia-related deaths. Five-year survival of patients maintained with the muscle flap stimulated at every other cardiac beat was 58.3% +/- 14.2%. Skeletal muscle stimulation protocols also influenced the long-term behavior of left ventricular ejection fraction.

CONCLUSIONS

Long-term results of dynamic cardiomyoplasty are limited by the patient's preoperative condition and by a high incidence of sudden cardiac death. These results may be improved using modified skeletal muscle stimulation protocols and cardioverter-defibrillator implantation, while maintaining dynamic cardiomyoplasty as an option for selected patients.

Right ventricular cardiomyoplasty: 10-year follow-up

BACKGROUND

Chronically depressed right ventricular (RV) function presents an unsolved therapeutic challenge in cardiac surgery. Despite recent advances in medical and surgical therapies, prognosis remains poor and patient's quality of life and mortality are frequently unacceptable. The aim of this study is to present the first clinical report and long-term results of RV dynamic cardiomyoplasty applied in patients with RV failure caused by isolated RV cardiomyopathies.

METHODS

Seven consecutive patients (5 males, 2 females; mean age, 40 +/- 9 years; range, 15 to 63 years) from a series of 113 cardiomyoplasty procedures performed at Broussais and Pompidou Hospitals were evaluated. The mean duration of follow-up was 10 +/- 3.5 years. All patients had predominant RV dysfunction, associated with tricuspid regurgitation in 6 patients. The cause of RV failure was arrhythmogenic cardiomyopathy (4 patients), ischemic (2 patients), and Uhl's disease (1 patient), and endomyocardial fibrosis (1 patient). Six patients were in preoperative New York Heart Association functional class III and 1 was in intermittent class III/IV. The mean preoperative ejection fraction (measured by isotopic technique) was 18% +/- 5.7% for the right ventricle and 40% +/- 13% for the left ventricle. Right ventricular dynamic cardiomyoplasty consists of wrapping the RV free walls with the left latissimus dorsi muscle flap. The distal part of the latissimus dorsi muscle is fixed to the diaphragm and then electrostimulated. Six patients required associated tricuspid valve surgery.

RESULTS

There were no perioperative deaths. The mean duration of follow-up was 10 +/- 3.5 years. Six patients are alive with a remarkable quality of life, 4 are in New York Heart Association functional class I and 2 are in class II. One patient who was in New York Heart Association functional class II died in postoperative year 7 caused by stroke. At last follow-up, mean RV ejection fraction was 33% +/- 11.8% and left ventricular ejection fraction was 52% +/- 12.6%.

CONCLUSIONS

The results of this long-term study demonstrate hemodynamic and functional improvements after RV cardiomyoplasty without perioperative mortality, no long-term malignant arrhythmias, and RV dysfunction related deaths. We believe that RV cardiomyoplasty, associated with tricuspid valve surgery when required, could be an effective treatment for severe RV failure.

Demand dynamic bio-girdling in heart failure: improved efficacy of dynamic cardiomyoplasty by LD contraction during aortic out-flow

PURPOSE

The value of dynamic cardiomyoplasty has been brought into question by the disappointing results produced by slow contraction-relaxation cycle and possibly degeneration of the latissimus dorsi muscle (LD) secondary to temporary tenotomy and chronic daily electrical stimulation. Objective of our study is to determine whether daily periods of rest introduced by demand stimulation in the continuous contraction protocol produce systolic assistance and improve clinical results.

METHODS

Twelve dynamic cardiomyoplasty patients (mean age 58.2 +/- 5.8 years, M/F=11/1, sinus rhythm/atrial fibrillation=11/1) with dilated myocardiopathy were enrolled in an unrandomized trial of Demand Dynamic Heart Bio-Girdling in a public regional teaching hospital. Periods of LD inactivity, each lasting several hours, were introduced daily on a heart rate-based demand regime. To avoid full transformation of LD, fewer impulses per day were delivered, daily providing the LD with long periods of rest (Demand light stimulation). The contractile properties were measured by transcutaneous non-invasive LD tensiomyogram interrogation (LD tensiomyogram). Bio-Girdle activation was synchronized to heart beat by combining tensiomyogram and echocardiography. Clinical, echocardiographic and hemodynamic records, as well as aortic flow measurements by Doppler aortic flow wire were taken during the follow-up.

MAIN FINDINGS

Mean duration of the demand stimulation follow-up was 40.2+13.8 months. At five years, "Demand stimulation" shows: 1) no operative death; 2) 83% actuarial survival; 3) highly significant 47.4% decrease of the NYHA class (from 3.17 +/- 0.38 to 1.67 +/- 0.77, p=0.0001); 4) 41.6% improvement of LVEF (from 22.6 +/- 4.38 to 32.0 +/- 7.0, p=0.001); 5) 7.5 +/- 3.0% increase in aortic flow velocity peak in assisted vs. unassisted beats, and 6) preservation of LD from slowness (TFF value 33 +/- 7.86 at follow-up versus 15.8 +/- 11.1 Hz just before switching from continuous to demand stimulation, p=0.0001) and muscle degenerative atrophy.

CONCLUSIONS

In dynamic cardiomyoplasty the demand light stimulation maintains LD contraction properties over time, produces effective systolic assistance, and improves clinical results. Demand dynamic bio-girdling is a safe and effective treatment for end-stage heart failure in selected patients.