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Karigyo CJT, Pessoa BMS, Nicacio SP, Terwilliger E, Costa P, dos Santos PR, Ernani V, Seetharam M, Murakami AN, Batalini F. Cardiac Tumors: Review. Braz J Cardiovasc Surg 2024; 39:e20230405. [PMID: 39038269 PMCID: PMC11262154 DOI: 10.21470/1678-9741-2023-0405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/12/2024] [Indexed: 07/24/2024] Open
Abstract
Cardiac tumors are rare and encompass a variety of presentations. Clinica symptoms are usually nonspecific, but they can present as obstructive, embolic, or constitutional symptoms. Treatment options and prognosis vary highly depending on the subtype, tumor size, and location. Surgical resection is usually the first-line therapy, except for cardiac lymphomas, and provides favorable long-term prognosis in most benign tumors. Cardiac sarcomas, however, are usually diagnosed in advanced stages, and the treatment relies on a multimodal approach with chemotherapy and radiotherapy. Metastatic cardiac tumors are usually related to advanced disease and carry an overall poor prognosis.
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Affiliation(s)
- Carlos J. T. Karigyo
- Engineering Center for Circulatory Assistance, Instituto Dante
Pazzanese de Cardiologia, São Paulo, São Paulo, Brazil
- Postgraduate Program in Medicine/Technology and Intervention in
Cardiology, Universidade de São Paulo, São Paulo, São Paulo,
Brazil
| | | | | | - Emma Terwilliger
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota,
United States of America
| | - Philippos Costa
- Division of Hematology and Oncology, Yale University Yale Cancer
Center, New Haven, Connecticut, United States of America
| | - Pedro Reck dos Santos
- Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix,
Arizona, United States of America
| | - Vinicius Ernani
- Division of Oncology, Mayo Clinic Arizona, Phoenix, Arizona, United
States of America
| | - Mahesh Seetharam
- Division of Oncology, Mayo Clinic Arizona, Phoenix, Arizona, United
States of America
| | | | - Felipe Batalini
- Division of Oncology, Mayo Clinic Arizona, Phoenix, Arizona, United
States of America
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Pimentel J, Suero Taveras G, Floriani Alvarez A. Unusual Presentation of Cardiac Myxoma Mimicking Chronic Obstructive Pulmonary Disease (COPD) Exacerbation: A Report of a Rare Case. Cureus 2024; 16:e61967. [PMID: 38978913 PMCID: PMC11230137 DOI: 10.7759/cureus.61967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/10/2024] Open
Abstract
A cardiac myxoma is an authentic tumor that develops within the heart. Despite the typically benign histological characteristics, a cardiac myxoma may, on occasion, exhibit behavior reminiscent of malignant tumors. Most of these myxomas localize in the left atrium, often originating from a stalk near the foramen ovale region. The conventional presentation of cardiac myxomas includes a combination of obstruction, clot formation, and systemic symptoms, mirroring various other prevalent systemic diseases. They may manifest either spontaneously or through hereditary transmission. While familial myxomas are commonly linked to discernible genetic mutations, the precise molecular mechanisms underlying spontaneous myxomas remain somewhat enigmatic. Many individuals with myxomas may remain asymptomatic. However, should symptoms manifest, they can prove nonspecific and pose challenges in interpretation, particularly in instances of spontaneous heart myxomas. This report describes a 58-year-old female patient who presented with increasing severity of exertional dyspnea over a six-month duration. Initial differential diagnoses included common pulmonary and cardiac conditions, with a primary focus on chronic obstructive pulmonary disease and congestive heart failure. An echocardiogram revealed a large mass in the left atrium suggestive of a cardiac myxoma. Surgical resection confirmed the diagnosis. This case underscores the significance of including cardiac myxoma in differential diagnoses for progressive exertional dyspnea. Early detection and surgical intervention are crucial in mitigating potential complications like stroke, heart failure, or sudden cardiac death.
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Affiliation(s)
- Jorge Pimentel
- Internal Medicine, CEDIMAT (Centros de Diagnóstico, Medicina Avanzada y Telemedicina), Santo Domingo, DOM
| | - Gabriela Suero Taveras
- Internal Medicine, CEDIMAT (Centros de Diagnóstico, Medicina Avanzada y Telemedicina), Santo Domingo, DOM
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Francesco B, Martina O, Maria Letizia C, Serena G, Cerinic Marco M. Seronegative enthesoarthritis as the first presentation of the atrial myxoma. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:167-170. [PMID: 37781684 PMCID: PMC10538594 DOI: 10.2478/rir-2023-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 01/26/2023] [Indexed: 10/03/2023]
Abstract
Atrial myxoma (AM) is the most common primary cardiac tumor. Its clinical presentation can be highly heterogeneous and can be characterized by many constitutional manifestations and development of rheumatologic symptoms.We report the case of a patient presenting with a seronegative arthritis characterized by articular and enthesis involvement and purpuric cutaneous lesions that was refractory to conventional treatments and that was later diag- nosed with an AM as first cause of the manifestations. AM can present with different symptoms; among them, it is able to cause some rheumatological manifestation as it is able to secrete proinflammatory cytokines, as interleukin 6 (IL-6), tumor necrosis factor α (TNF-α), and interferon γ (IFN-γ). The present case is of particular interest as it presents an AM as the cause of an inflammatory arthropathy with articular and enthesis involvement. A paraneoplastic screening is always relevant in rheumatology, especially when encountering a refractory disease.
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Affiliation(s)
- Bonomi Francesco
- Department of Clinical and Experimental Medicine, University of Florence, 50134Florence, Italy
| | - Orlandi Martina
- Department of Clinical and Experimental Medicine, University of Florence, 50134Florence, Italy
| | - Conforti Maria Letizia
- Department of Clinical and Experimental Medicine, University of Florence, 50134Florence, Italy
| | - Guiducci Serena
- Department of Clinical and Experimental Medicine, University of Florence, 50134Florence, Italy
| | - Matucci Cerinic Marco
- Department of Clinical and Experimental Medicine, University of Florence, 50134Florence, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132Milan, Italy
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Karch J, Raja A, De La Garza H, De Jesus Diaz Zepeda A, Shih A, Maymone MBC, Phillips TJ, Secemsky E, Vashi N. Part I: Cutaneous manifestations of cardiovascular disease. J Am Acad Dermatol 2023; 89:197-208. [PMID: 35504486 DOI: 10.1016/j.jaad.2021.06.902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 11/25/2022]
Abstract
In this part 1 of a 2-part continuing medical education series, we review the epidemiology and pathophysiology of cardiovascular disease, its association with cutaneous symptoms, and the diagnosis and evaluation of cutaneous features of cardiovascular syndromes, including infective endocarditis, acute rheumatic fever, Kawasaki disease, cholesterol embolization syndrome, lipid disorders, cardiac amyloidosis, and cardiac myxomas. As the incidence and prevalence of cardiovascular diseases increase, dermatologists play an essential role in recognizing the cutaneous manifestations of cardiovascular diseases in order to appropriately connect patients with follow-up care.
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Affiliation(s)
- Jamie Karch
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aishwarya Raja
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Henriette De La Garza
- Departments of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | | | - Allen Shih
- Departments of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Mayra B C Maymone
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Tania J Phillips
- Departments of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Eric Secemsky
- Smith Center for Outcomes Research, Departments of Cardiology and Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Neelam Vashi
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; Department of Dermatology, US Department of Veteran Affairs, Boston Health Care System, Boston, Massachusetts.
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Ma L, Cai B, Qiao ML, Fan ZX, Fang LB, Wang CB, Liu GZ. Risk factors assessment and a Bayesian network model for predicting ischemic stroke in patients with cardiac myxoma. Front Cardiovasc Med 2023; 10:1128022. [PMID: 37034338 PMCID: PMC10079949 DOI: 10.3389/fcvm.2023.1128022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Objective This study aims to identify relevant risk factors, assess the interactions between variables, and establish a predictive model for ischemic stroke (IS) in patients with cardiac myxoma (CM) using the Bayesian network (BN) approach. Methods Data of patients with CM were collected from three tertiary comprehensive hospitals in Beijing from January 2002 to January 2022. Age, sex, medical history, and information related to CM were extracted from the electronic medical record system. The BN model was constructed using the tabu search algorithm, and the conditional probability of each node was calculated using the maximum likelihood estimation method. The probability of each node of the network and the interrelationship between IS and its related factors were qualitatively and quantitatively analyzed. A receiver operating characteristic (ROC) curve was also plotted. Sensitivity, specificity, and area under the curve (AUC) values were calculated and compared between the BN and logistic regression models to evaluate the efficiency of the predictive model. Results A total of 416 patients with CM were enrolled in this study, including 61 with and 355 without IS. The BN model found that cardiac symptoms, systemic embolic symptoms, platelet counts, and tumor with high mobility were directly associated with the occurrence of IS in patients with CM. The BN model for predicting CM-IS achieved higher scores on AUC {0.706 [95% confidence interval (CI), 0.639-0.773]} vs. [0.697 (95% CI, 0.629-0.766)] and sensitivity (99.44% vs. 98.87%), but lower scores on accuracies (85.82% vs. 86.06%) and specificity (6.56% vs. 11.48%) than the logistic regression model. Conclusion Cardiac symptoms, systemic embolic symptoms, platelet counts, and tumor with high mobility are candidate predictors of IS in patients with CM. The BN model was superior or at least non-inferior to the traditional logistic regression model, and hence is potentially useful for early IS detection, diagnosis, and prevention in clinical practice.
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Affiliation(s)
- Lin Ma
- Department of Neurology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bin Cai
- Department of Neurology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Man-Li Qiao
- Department of General Practice Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ze-Xin Fan
- Department of Neurology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Li-Bo Fang
- Department of Neurology, Beijing Fangshan District Liangxiang Hospital, Beijing, China
| | - Chao-Bin Wang
- Department of Neurology, Beijing Fuxing Hospital, Capital Medical University, Beijing, China
| | - Guang-Zhi Liu
- Department of Neurology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Correspondence: Guang-Zhi Liu
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Bahloul A, Sarray H, Kammoun Y, Charfeddine S, Gueldich M, Dammak A, Frikha I, Abid L, Hammami R, Kammoun S. Giant Left Atrial Myxoma with Mitral Valve Obstruction. J Cardiovasc Echogr 2021; 31:110-112. [PMID: 34485040 PMCID: PMC8388329 DOI: 10.4103/jcecho.jcecho_111_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/08/2021] [Accepted: 03/29/2021] [Indexed: 11/25/2022] Open
Abstract
Cardiac myxomas are the most common primary intracardiac tumors in adults. Although benign from a histopathological point of view, they can be life-threatening for the patient. We present a case of an unusually giant left atrial myxoma causing mitral valve obstruction and pulmonary hypertension successfully treated with surgical resection. Our patient was a 54-year-old woman who presented to our emergency complaining of progressive dyspnea of about 1 month duration. On cardiovascular examination, we found crackling rales at both lung bases and a diastolic murmur in the mitral focus. Transthoracic echocardiography revealed a giant mass in the left atrium connected to the interatrial septum and extended into the left ventricle during diastole which caused obstruction of the left ventricular inflow tract and a pulmonary hypertension. The patient underwent a median sternotomy with the removal of left atrial mass and patch closure of the interatrial septum. Histopathological examination confirmed the diagnosis of myxoma. One week later, the patient was discharged without any complications. Giant left atrial myxoma although a benign mass, can induce dramatic symptoms and be life-threatening. In case of suspicion, it must be diagnosed early by transthoracic echocardiography and urgently managed by surgical removal.
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Affiliation(s)
- Amine Bahloul
- Department of Cardiology, Hedi Chaker Hospital, Sfax University, Sfax, Tunisia
| | - Hela Sarray
- Department of Cardiology, Hedi Chaker Hospital, Sfax University, Sfax, Tunisia
| | - Yassmine Kammoun
- Department of Cardiology, Hedi Chaker Hospital, Sfax University, Sfax, Tunisia
| | - Selma Charfeddine
- Department of Cardiology, Hedi Chaker Hospital, Sfax University, Sfax, Tunisia
| | - Majdi Gueldich
- Department of Cardiovascular Surgery, Habib Bourguiba Hospital, Sfax University, Sfax, Tunisia
| | - Aymen Dammak
- Department of Cardiovascular Surgery, Habib Bourguiba Hospital, Sfax University, Sfax, Tunisia
| | - Imed Frikha
- Department of Cardiovascular Surgery, Habib Bourguiba Hospital, Sfax University, Sfax, Tunisia
| | - Leila Abid
- Department of Cardiology, Hedi Chaker Hospital, Sfax University, Sfax, Tunisia
| | - Rania Hammami
- Department of Cardiology, Hedi Chaker Hospital, Sfax University, Sfax, Tunisia
| | - Samir Kammoun
- Department of Cardiology, Hedi Chaker Hospital, Sfax University, Sfax, Tunisia
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Almeida FS, Canevazzi GJ, Rocha PB, Sobral ACCM, Sobral MLP. Tumoration in Anterior Leaflet of the Mitral Valve. Braz J Cardiovasc Surg 2021; 36:116-119. [PMID: 33594865 PMCID: PMC7918378 DOI: 10.21470/1678-9741-2020-0557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | | | - Priscila Barão Rocha
- Faculdade de Medicina, Centro Universitário das Américas, São Paulo, São Paulo, Brazil
| | | | - Marcelo Luiz Peixoto Sobral
- Faculdade de Medicina, Centro Universitário das Américas, São Paulo, São Paulo, Brazil.,Departament of Cardiovascular Surgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, São Paulo, Brazil.,Post Graduate Department of Cardiovascular and Thoracic Surgery, Universidade de São Paulo, Instituto do Coração, São Paulo, São Paulo, Brazil
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8
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Abstract
Every year, more than 795,000 people in the United States have a stroke, the vast majority of which are ischemic. Cardiac myxoma is an unusual cause of stroke and accounts for less than 1% of ischemic strokes. We present a case of a 56-year-old male with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus, who presented with altered mental status, tinnitus, double vision, and diaphoresis. Due to concern for a cerebral vascular accident, a CT scan of the brain was obtained and showed no acute intracranial process. Brain MRI revealed multiple small acute infarcts involving bilateral posterior cerebral artery distribution. Further evaluation included transthoracic echocardiography that showed a large mobile mass in the left atrium measuring 3.5 x 2 cm intermittently projecting through the mitral valve. The patient underwent successful surgical resection of the left atrial mass. The pathology report confirmed the diagnosis of atrial myxoma. This case further highlights the importance of complete evaluation of stroke, including echocardiography, as well as the importance of careful surgical resection to prevent recurrence of systemic embolization and other complications of atrial myxoma.
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Affiliation(s)
| | - Emad Kandah
- Internal Medicine, McLaren Health Care, Michigan State University, Flint, USA
| | - Basel Abdelazeem
- Internal Medicine, McLaren Health Care, Michigan State University, Flint, USA
| | - Saed Alnaimat
- Cardiology, McLaren Health Care, Michigan State University, Flint, USA
| | - Arvind Kunadi
- Internal Medicine, McLaren Health Care, Michigan State University, Flint, USA
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9
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Guk HS, Lee S, Jeong HB, Ju W, Choi JS, Lee YS. Recurrent Embolic Stroke Associated with Long-Latency Relapsing Cardiac Myxoma. J Clin Neurol 2019; 15:591-593. [PMID: 31591856 PMCID: PMC6785467 DOI: 10.3988/jcn.2019.15.4.591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/27/2019] [Accepted: 06/27/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Hyung Seok Guk
- Department of Neurology, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seonkyung Lee
- Department of Neurology, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Bong Jeong
- Department of Neurology, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woohee Ju
- Department of Neurology, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Sung Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Seok Lee
- Department of Neurology, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea.
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10
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Epidemiology, aetiology, and management of ischaemic stroke in young adults. Lancet Neurol 2019; 17:790-801. [PMID: 30129475 DOI: 10.1016/s1474-4422(18)30233-3] [Citation(s) in RCA: 214] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/01/2018] [Accepted: 06/05/2018] [Indexed: 01/15/2023]
Abstract
Epidemiological evidence suggests that the incidence of ischaemic stroke in young adults (18-50 years) has increased substantially. These patients have a long life expectancy after stroke, and the costs of long-term care pose huge challenges to health-care systems. Although the current recommendations for treatment of young and old (>50 years) patients with stroke are similar, the optimal management of young adult patients with stroke is unknown. They are usually not included in trials, and specific subanalyses limited to young adult patients with stroke are usually not done, owing to lower incidence of stroke and lower prevalence of vascular risk factors in young adults. Progress has been made in identifying patients with a considerable risk of stroke occurrence, such as those with patent foramen ovale. Future prevention studies might result in a decrease in the incidence of stroke and its sequelae in young adults. The development of guidelines specifically devoted to the management of stroke in young adults will be an important step in achieving this aim.
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Karabinis A, Samanidis G, Khoury M, Stavridis G, Perreas K. Clinical presentation and treatment of cardiac myxoma in 153 patients. Medicine (Baltimore) 2018; 97:e12397. [PMID: 30213011 PMCID: PMC6155961 DOI: 10.1097/md.0000000000012397] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Cardiac myxoma (CM) is the most common benign cardiac tumor. We retrospectively reviewed our single center experience in 153 patients with CM over a period 25 years.From November 1993 to May 2017, 153 patients were operated in our institution with diagnosis of a CM. In all patients preoperative, perioperative, and postoperative data were recorded including the long-term follow-up. All patients followed up in the outpatient's clinics and echocardiography at regular intervals.Mean age 59 ± 12 years old. There were 104 women and 49 men. Preoperative clinical manifestations of the patients were hemodynamic consequences (47.7%), asymptomatic (46.4%), systemic embolism (4.5%), systemic manifestations-fever (0.7%), and hemoptysis (0.7%). The most common location of CM was in the left atrium in 82.4% patients. Mean tumors diameter was 4.5 ± 1.9 cm. In addition, we were observed that the age of the patients have differences between sex groups women versus men, 60.3 and 54.8 years old respectively (P = .02). On the other hand the tumor size have not differences between the sex groups (P = .56). Combine operations were performed in 24 (15.7%) patients. New cerebrovascular accident was observed in 2 patients post-op. Mean in-hospital stay was 8.02 ± 2.8 days. In-hospital mortality was 1 patient (0.7%) (from sepsis). During median follow-up 3.7 ± 4.3 years CM recurrence was identified in 5 (3.3%) patients.Surgical resection of CMs contributes in an excellent prognosis and associated with low complications and recurrences rate. Regular long-term follow-up is recommended in all patients with CM.
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Affiliation(s)
| | | | | | - George Stavridis
- Third Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
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12
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AbuHalimeh B, Desai MY, Tonelli AR. Effect of abnormal right heart structures on the diagnosis of pulmonary hypertension. Pulm Circ 2018; 8:2045894018773053. [PMID: 29671686 PMCID: PMC5946618 DOI: 10.1177/2045894018773053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The diagnosis of pulmonary hypertension (PH) requires a right heart catheterization (RHC) that reveals a mean pulmonary artery pressure ≥ 25 mmHg. The pulmonary artery catheter traverse the right atrium and ventricle on its way to the pulmonary artery. The presence of abnormal right heart structures, i.e. thrombus, vegetation, benign or malignant cardiac lesions, can lead to complications during this procedure. On the other hand, avoidance of RHC delays the diagnosis and treatment of PH, an approach that might be associated with worse outcomes. This paper discusses the impact of right heart lesions on the diagnosis of PH and suggests an approach on how to manage this association.
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Affiliation(s)
- Batool AbuHalimeh
- 1 2569 Pathobiology Division, Lerner Research Institute, Cleveland Clinic, OH, USA
| | - Milind Y Desai
- 2 2569 Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- 1 2569 Pathobiology Division, Lerner Research Institute, Cleveland Clinic, OH, USA.,3 Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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