Ann Thorac Surg 1997;63:841-843
© 1997 The Society of Thoracic Surgeons
Case Reports
Resection of Left Ventricular Tumor Using Videocardioscopy and Echocardiography
Blaine Nease, MD,
Patricia Conant, MS,
Aubyn Marath, FRCS,
Peter P. McKeown, FRACS
Division of Cardiovascular and Thoracic Surgery, University of South Florida, Tampa, Florida
Accepted for publication October 14, 1996.
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Abstract
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Assessment of large cardiac tumors requires careful definition of the extent, cell type, and degree of invasiveness to determine the best operative management. Preoperative magnetic resonance imaging and echocardiography were helpful, but limited in the assessment and management in the case of a 19-year-old pregnant woman with a large (9 x 5.5-cm) left ventricular mass. Intraoperative echocardiography and videocardioscopy facilitated precise operative decisions and management. Successful resection was achieved without the need for cardiac transplantation. This case demonstrates the complexity of the diagnosis and management of large cardiac tumors.
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Introduction
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Primary cardiac tumors are rare. Postmortem studies confirm an incidence of 0.2% to 0.3% [1]. Twenty-five percent of primary tumors are malignant, predominantly various forms of sarcoma. Initial management includes determination of histologic status, tumor extent, and the degree of invasiveness, and whether resection or reconstruction will secure adequate hemodynamic recovery versus the need for transplantation [2, 3]. Magnetic resonance imaging and two-dimensional echocardiography are recommended to determine operability and project postoperative hemodynamic results after resection [4].
A 19-year-old woman discovered a left breast lump during the 27th week of her pregnancy. During the workup for excision of this benign fibroadenoma, a routine electrocardiogram revealed T-wave inversion in the left ventricular leads, prompting a two-dimensional echocardiogram, which showed a large echogenic mass extending from the apex along the entire posterior wall of the left ventricle. The wall was akinetic, with the mass encroaching into the left ventricular cavity. No aortic or mitral flow obstruction was observed. The ejection fraction was 0.52. Cine magnetic resonance imaging further delineated the mass (9 x 5.5 cm) arising from the epicardial portion of the left ventricular free wall (Fig 1
). The signal was nearly identical to that of the myocardium. The tumor appeared to merge at the atrioventricular junction and in continuity with the mitral valve apparatus.
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Fig 1. . Magnetic resonance image showing massive left ventricular tumor measuring 9 x 5.5 cm arising from the epicardial portion of the left ventricular free wall.
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The patient remained hemodynamically stable throughout the third trimester of her pregnancy, even though the tumor slowly increased in size, demonstrated by serial echocardiograms. Holter monitoring revealed several episodes of nonsustained ventricular tachycardia successfully treated with ß-blockers. She had an uneventful, but carefully monitored vaginal delivery of a normal full-term infant. Cardiac catheterization 2 months after delivery showed a filling defect involving the inferoposterolateral portion of the left ventricle. There was no tumor blush or coronary anatomy. A left ventricular endomyocardial biopsy was done, but was not diagnostic.
Three months after delivery a decision was made to perform a median sternotomy, biopsy of the tumor intraoperatively, and an attempt at resection. At the time of operation the tumor was in continuity with the ventricular myocardium extending to the atrioventricular groove. An intraoperative biopsy confirmed the diagnosis of a benign fibroma. Combined intraoperative transesophageal and epicardial echocardiography revealed an intact mitral valve apparatus and helped delineate the extent of the tumor and feasibility of resection. The patient was placed on cardiopulmonary bypass, and under hypothermic cardioplegic arrest the tumor was carefully shelled out from normal muscle. A limited (0.5-cm) ventriculotomy was used for the introduction of rigid and flexible cardioscopes to further assess the extent of the tumor from an endocardial perspective.
There was no endocardial extension or intracavitary thrombus seen. The tumor was totally resected and measured 9 x 5.5 cm. The ventriculotomy was repaired using a pursestring suture (2-0 polypropylene) with additional interrupted mattress pledgeted sutures. The ventricular margins were approximated, providing a geometric arrangement, and were reinforced with strips of pericardium. The patient was weaned from cardiopulmonary bypass without inotropic or left ventricular assist device support and was discharged on the sixth postoperative day. Twenty-two months after the operation she remains asymptomatic.
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Comment
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Accurate preoperative assessment of cardiac tumors can be complex. In this case, current echocardiographic and radiographic modalities were helpful but inconclusive. Absence of histologic diagnosis preoperatively with the inability to visualize the extent of the tumor encroachment on the mitral valve were major concerns. Although benign fibroma was suspected, we were unable to obtain adequate tissue for diagnosis with an endomyocardial biopsy. The age of the patient and presentation during pregnancy were unusual. Ninety percent of cardiac fibromas occur in patients less than 12 years of age, and 75% occur in patients less than 2 years of age [5–7]. The pregnancy delayed operative intervention, during which time the tumor enlarged and dysrhythmias occurred.
Cine magnetic resonance imaging (gated with the electrocardiogram) was favored over contrast-induced computed tomographic scan to better identify myocardial structural relationships, evaluate the mass in motion with the cardiac cycle, and determine the relationship and possible invasiveness into the mitral valve structures. An operative approach was undertaken for diagnosis and planned resection. A median sternotomy was favored over thoracotomy for its improved visualization and access for cardiopulmonary bypass. Intraoperative videocardioscopy and epicardial echocardiography were used to further enhance the decision process as to resectability. These techniques provided assessment of the intraventricular cavity, subvalvular mitral apparatus, ventricular septum, and aortic outflow tract without the need for a large ventriculotomy incision.
In conclusion, diagnosis, management, and treatment of large cardiac tumors may be difficult even with an array of diagnostic modalities. In this unusual case, extensive diagnostic efforts were used preoperatively to determine histology, extent, and resectability, but a definitive operative approach was ultimately required. The use of intraoperative biopsy, epicardial echocardiography, and adjunctive videocardioscopy complemented the assessment and management of this case in achieving successful resection of a massive left ventricular fibroma.
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Footnotes
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Address reprint requests to Dr McKeown, 4 Columbia Dr, #730, Tampa, FL 33606.
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References
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- Silverman NA. Primary cardiac tumors. Ann Surg 1980;191:127–38.[Medline]
- Jamieson SW, Gaudiani VA, Reitz BA, Oyer PE, Stinson EB, Shumway NE. Operative treatment of an unresectable tumor of the left ventricle. J Thorac Cardiovasc Surg 1981;81:797–9.[Abstract]
- Valente M, Cocco P, Theine G, et al. Cardiac fibroma and heart transplantation. J Thorac Cardiovasc Surg 1993;106:1208–11.[Abstract]
- Bini RM, Westaby S, Bargeron LM Jr, Pacifico AD, Kirklin JW. Investigation and management of primary cardiac tumors in infants and children. J Am Coll Cardiol 1983;2:351–7.[Abstract]
- Williams DB, Danielson GK, McGoon DC, Feldt RH, Edwards WD. Cardiac fibroma: long term survival after excision. J Thorac Cardiovasc Surg 1982;84:230–6.[Abstract]
- Yamaguchi M, Hosokawa Y, Ohashi H, Imai M, Oshima Y, Minamiji K. Cardiac fibroma. Long-term fate after excision. J Thorac Cardiovasc Surg 1992;103:140–5.[Abstract]
- Marin-Garin J, Fitch CW, Shenefelt RE. Primary right ventricular fibroma simulating cyanotic heart disease in a newborn. J Am Coll Cardiol 1984;3:868–71.[Abstract]
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Abstract
Introduction
