Ann Thorac Surg 1999;67:852-854
© 1999 The Society of Thoracic Surgeons
Case Reports
Echocardiography and excision of lipomatous hypertrophy of the interatrial septum
Donald C. Oxorn, MDa,c,
Gerald Edelist, MDa,
Bernard S. Goldman, MDb,
Campbell D. Joyner, MDc
a Department of Anaesthesia, Sunnybrook Health Science Centre and the University of Toronto, Toronto, Ontario, Canada
b Division of Cardiovascular Surgery, Sunnybrook Health Science Centre and the University of Toronto, Toronto, Ontario, Canada
c Division of Cardiology, Sunnybrook Health Science Centre and the University of Toronto, Toronto, Ontario, Canada
Accepted for publication September 10, 1998.
Address reprint requests to Dr Oxorn, Department of Anesthesiology, University of Washington, Box 356540, Seattle, WA 98195-6540
e-mail: oxorn{at}u.washington.edu
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Abstract
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We present a case of massive lipomatous hypertrophy of the interatrial septum, in which transesophageal echocardiography was used to guide surgical resection. Tissue removal was undertaken without entering either the left or right atrium, thereby obviating the need for atrial septal reconstruction.
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Introduction
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Lipomatous hypertrophy of the interatrial septum is a pathologic entity characterized by large deposition of unencapsulated fetal and mature fat in the interatrial septum. The septum cephalad and caudad to the fossa ovalis may be involved, although the cephalad portion tends to be thicker; the fossa ovalis itself is generally spared [1–3]. There may be extension into the right atrial cavity, or through the interatrial (Waterston’s) groove onto the epicardial surface of the right or both atria [4]. Maximal diameters of 10 to 65 mm have been reported. The diagnosis is usually made at postmortem examination, or when cardiac operation or echocardiography is undertaken for other reasons. Clinical associations include advanced age, obesity, dyspnea, signs and symptoms of superior vena caval (SVC) obstruction, and supraventricular arrhythmias [1, 3]. The appearance on transesophageal echocardiography (TEE) and other noninvasive imaging studies is fairly characteristic, although pathologic confirmation may be attempted with endomyocardial biopsy [5]. Although the natural history of this condition is not well understood and the optimal treatment controversial, surgical resection should be contemplated when there is SVC obstruction or an intractable rhythm disturbance [6, 7]. Potential for important morbidity exists when large portions of the interatrial septum are excised.
We present a case of massive lipomatous hypertrophy of the interatrial septum in which resection was guided by TEE, in the hope of avoiding damage to the interatrial septum.
The patient, a 69-year-old white man, presented with increasing shortness of breath on exertion. His past medical history was unremarkable, except for chronic obstructive lung disease, intermittent atrial fibrillation that was treated with digoxin and coumadin, and moderate alcohol consumption. He had a ruddy complexion, but the jugular venous pulse was normal, and there was no upper body venous distention. Transthoracic echocardiogram showed atrial septal hypertrophy, with a large pedunculated mass attached. Computed tomography revealed a mass of fat arising from the posterior wall of the right atrium. Magnetic resonance imaging was interpreted as showing a fatty mass, 62 mm in diameter, arising from the atrial septum and compressing the SVC without proximal venous distention. Cardiac catheterization revealed insignificant coronary artery disease. The clinical picture was strongly suggestive of lipomatous hypertrophy of the interatrial septum, although malignant infiltration could not be ruled out.
Transesophageal echocardiography showed bilobed hypertrophy of the interatrial septum, with sparing of the fossa ovalis. There was extension through the interatrial groove, with a large mass superior and posterior to the right atrium that caused narrowing of the SVC-atrial junction (Figs 1 and 2) ; the mass measured approximately 50 mm in its largest diameter. Fatty infiltration was also seen at the base of the aorta. There was no encroachment on the tricuspid valve or the inferior vena cava.
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Fig 1. Transesophageal echocardiogram, 135-degree plane. Lipomatous hypertrophy of the interatrial septum (IAS) with sparing of the fossa ovalis (FO). The septum cephalad to the FO is 50 mm in its greatest diameter, and is causing constriction of the cavoatrial junction. (LA = left atrium; RA = right atrium; SVC = superior vena cava.)
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Fig 2. Transesophageal echocardiogram, zero-degree plane. Lipomatous hypertrophy is seen overlying the right atrium; the superior vena cava (SVC) is displaced anteriorly and compressed. (IAS = interatrial septum; LA = left atrium; PA = pulmonary artery.)
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In the operating room, femoral venous and arterial cannulation were followed by sternotomy and cannulation of the SVC above the cavoatrial junction. The heart was decompressed, but not arrested. Under TEE guidance, the tumor was debulked. A combination of both sharp and blunt dissection into the interatrial groove allowed the removal of a vast amount of the fatty tumor without entering either the right atrium anteriorly or the left atrium posteriorly. The mass was too firm to allow removal by direct suction. The dissection continued around the right superior pulmonary vein and under the SVC onto the roof of the left atrium in the transverse sinus. No attempt was made to remove the fatty deposits at the base of the aorta. At the conclusion of the resection, the integrity of the interatrial septum had not been violated, and no repair was required (Fig 3). The patient was successfully weaned from cardiopulmonary bypass with a slow junctional rhythm that mandated ventricular pacing. The postoperative course was complicated by atrial flutter, which was electrically converted to sinus rhythm, and a sterile pericardial effusion, which was drained under echocardiographic guidance. The patient was discharged in good condition 3 weeks after operation.
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Fig 3. Transesophageal echocardiogram, zero-degree plane. The edge of resection of the lipomatous hypertrophy is indicated by the arrows. (LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.)
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Comment
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Surgical management of lipomatous hypertrophy of the interatrial septum is largely reserved for patients who show evidence of SVC obstruction, diagnosed either preoperatively with noninvasive imaging studies, or coincidentally at the time of cardiac operation. If complete excision is attempted, reconstruction of the interatrial septum, with either pericardium or Dacron, must be undertaken [6]. In our case, TEE was used to guide resection so that the constriction of the SVC could be relieved without septal injury. By demonstrating that there was no intraluminal mass in either the inferior vena cava or SVC, the use of TEE also allowed for safe venous cannulation before the institution of cardiopulmonary bypass [8].
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References
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Shirani J., Roberts W.C. Clinical, electrocardiographic, and morphologic features of massive fatty deposits ("lipomatous hypertrophy") in the atrial septum. J Am Coll Cardiol 1993;22:226-238.[Abstract]
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Prior J.T. Lipomatous hypertrophy of cardiac interatrial septum. Arch Pathol 1964;78:11-15.[Medline]
-
Basu S., Folliguet T., Anselmo M., et al. Lipomatous hypertrophy of the interatrial septum. Cardiovasc Surg 1994;2:229-231.[Medline]
-
Cohen I.S., Raiker K. Atrial lipomatous hypertrophy: lipomatous atrial hypertrophy with significant involvement of the right atrial wall. J Am Soc Echocardiogr 1993;6:30-34.[Medline]
-
Pochis W.T., Saeian K., Sagar K.B. Usefulness of transesophageal echocardiography in diagnosing lipomatous hypertrophy of the atrial septum with comparison to transthoracic echocardiography. Am J Cardiol 1992;70:396-398.[Medline]
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Zeebregts C.J.A.M., Hensens A.G., Timmermans J., Pruszczynski M.S., Lacquet L.K. Lipomatous hypertrophy of the interatrial septum: indication for surgery?. Eur J Cardiothorac Surg 1997;11:785-787.[Abstract]
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McNamara R.F., Taylor A.E., Panner B.J. Superior vena caval obstruction by lipomatous hypertrophy of the right atrium. Clin Cardiol 1987;10:609-610.[Medline]
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Rousou J.A., Tighe D.A., Rifkin R.D., et al. Echocardiography allows safer venous cannulation during excision of large right atrial masses. Ann Thorac Surg 1998;65:403-406.[Abstract/Free Full Text]
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Abstract
Introduction
