Ann Thorac Surg 1998;65:1784-1786
© 1998 The Society of Thoracic Surgeons
Case Reports
Surgical Treatment of Lipomatous Hypertrophy of the Interatrial Septum
Julian J. Alcocer, MDa,
William E. Katz, MDb,
Brack G. Hattler, MD, PhDa
a Division of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
b Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Accepted for publication December 30, 1997.
Address reprint requests to Dr Hattler, Division of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, C-700, Pittsburgh, PA 15213-2582
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Abstract
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We report a case of lipomatous hypertrophy of the interatrial septum in a patient with a recent syncopal episode and shortness of breath. Preoperative transesophageal echocardiography demonstrated a large tumor protruding from the interatrial septum. In addition, the patient was found to have significant coronary artery disease and a right internal carotid artery stenosis. The patient underwent successful resection of the mass with septal reconstruction, aortocoronary bypass, and right carotid endarterectomy. Histology of the mass was consistent with lipomatous hypertrophy.
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Introduction
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Lipomatous hypertrophy of the interatrial septum involves a nonencapsulated circumscribed mass of adipose tissue usually in continuity with the epicardial fat that infiltrates the atrial septum anterior or superior to the fossa ovalis [1–3]. The lesion may be associated with atrial arrhythmias, congestive heart failure, recurrent pericardial effusions, or sudden death [4]. The incidence of this anomaly is not well known, and autopsy studies report a 0.8% to 1.2% prevalence, mostly in obese patients more than 60 years of age and frequently with associated atherosclerotic coronary artery disease [2, 3, 6].
A 64-year-old man was admitted for evaluation of chest pain, dyspnea on exertion, and a recent syncopal episode. He had suffered a prior myocardial infarction and had chronic obstructive pulmonary disease. His weight was 100 kg. Physical examination revealed bilateral carotid bruits. On cardiac examination he had a normal S1 and S2 with no gallops, rubs, or murmurs. Neurologic examination was unremarkable. Electrocardiography revealed normal sinus rhythm with first-degree atrioventricular block and a nonspecific interventricular conduction delay. Chest roentgenography demonstrated a normal heart size and emphysematous lungs. Coronary angiography demonstrated the right coronary artery to be dominant with a midsegment 70% stenosis, a 60% left anterior descending stenosis, and an 80% ostial lesion in the second diagonal branch. A transesophageal echocardiogram demonstrated a protruding 4.7 by 4.4 cm right atrial mass with a broad-based attachment to the interatrial septum (Fig 1). A cerebral angiogram demonstrated a 75% right internal carotid artery stenosis.
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Fig 1. Transesophageal echocardiogram at the mid-esophageal level at 86 degrees. A broad-based mass (x) measuring 4.7 x 4.4 cm is attached to the interatrial septum. (LA = left atrium; RA = right atrium; SVC = superior vena cava.)
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At operation the carotid endarterectomy was completed first, followed by a median sternotomy with ascending aortic perfusion and bicaval venous return. A right atriotomy revealed a large (5 cm in maximum diameter) yellow-orange mass with no obvious capsule protruding into the right atrial cavity. This mass was shelled out, revealing a second fatty tumor 3.5 cm in diameter, which was also removed (Fig 2). The septum was left intact and the endocardium reapproximated with a running Prolene (Ethicon, Somerville, NJ) suture. The left internal mammary artery was then anastomosed to the left anterior descending coronary, and saphenous vein grafts were anastomosed to the right and diagonal coronary arteries.
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Fig 2. Gross pathologic specimens of the two atrial septal masses, which represent separate areas of lipomatous hypertrophy.
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Postoperatively the patient recovered without complications and was discharged on the fifth postoperative day. Histologically the mass was consistent with lipomatous hypertrophy and microscopically showed interspersed cardiac muscle fibers with a background of predominant adult fat cells.
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Comment
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The present case of lipomatous hypertrophy of the interatrial septum represents an uncommon cardiac tumor, presenting as a right atrial mass. Although the transesophageal echocardiogram was helpful in defining the location of the mass, it suggested the mass was a myxoma. Removal of the mass was successfully performed along with atrial septal reconstruction and surgical revascularization of the right carotid and coronary arteries.
The first successful excision of an epicardial lipoma was reported by Mauer in 1952 [6]. Crockett and associates [7] in 1964 reported the first successful removal of a lipoma arising from an atrial wall. Prior [1], in 1964, was the first to identify lipomatous hypertrophy of the interatrial septum as a different entity. He reported that this lesion was microscopically composed of mature fat cells with hypertrophic cardiac muscle cells distributed irregularly throughout the tumor. He indicated that lipomatous hypertrophy is a hypertrophic lesion of otherwise normal structures of the interatrial septum and can thus be differentiated from a heart lipoma, which is very rare [6, 7]. Grossly these two tumors, however, appear very similar and the surgical treatment is basically the same.
The first antemortem diagnosis of lipomatous hypertrophy of the interatrial septum occurred in 1982 [2]. Most of the reported cases occur in obese patients, and most commonly in women and white patients [5]. Atrial arrhythmias, particularly atrial premature contractions, atrial fibrillation, and supraventricular tachycardia, are common. Other reported findings include congestive heart failure, recurrent palpitations, dyspnea, pericardial effusions, and sudden death [2, 4, 5]. The majority of patients have significant atherosclerotic vascular disease, as was the case with our patient. Embolic symptoms are rare, and the tumor is usually discovered as an incidental finding at echocardiography, which accurately defines the lesion in the interatrial septum most commonly confused with a myxoma. It allows a precise approach to this tumor, which has a position that is always constant within the interatrial septum and should be included in the differential diagnosis of broad-based tumors in this location [8].
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References
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- Prior J.T. Lipomatous hypertrophy of cardiac interactial septum. Arch Pathol 1964;78:11-15.[Medline]
- Burke A.P., Litovsky S., Virmani R. Lipomatous hypertrophy of the atrial septum presenting as a right atrial mass. Am J Surg Pathol 1996;20:678-685.[Medline]
- Gay J.D., Guileyardo J.M., Townsend-Parchman J.K., et al. Clinical and morphologic features of lipomatous hypertrophy ("massive fatty deposits") of the interatrial septum. Am J Forensic Med Pathol 1996;17:43-48.[Medline]
- Zeebregts C.J.A.M., Hensens A.G., Timmermans J., et al. Lipomatous hypertrophy of the interatrial septum: indication for surgery. Eur J Cardiothorac Surg 1997;11:785-787.[Abstract/Free Full Text]
- Reyes C.V., Jablokow V.R. Lipomatous hypertrophy of the cardiac interatrial septum. Am J Clin Pathol 1979;72:785-788.[Medline]
- Mauer E.R. Successful removal of a tumor of the heart. J Thorac Surg 1952;3:479-482.
- Crockett J.E., Decker D., Reed W., et al. Lipoma of the heart. Am J Card 1964;14:394-398.
- Borges A.C., Witt C., Bartel T., et al. Preoperative two and three dimensional transesophageal echocardiographic assessment of heart tumors. Ann Thorac Surg 1996;61:1163-1167.[Abstract/Free Full Text]
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Abstract
Introduction
