Ann Thorac Surg 1999;68:580-582
© 1999 The Society of Thoracic Surgeons
Case Reports
Left ventricular fibroma masquerading as postinfarction myocardial rupture
K. Adam Lee, MDa,
Joseph G. Kirkpatrick, MDa,
John M. Moran, MDa,
A. Thomas Pezzella, MDa
a Department of Cardiothoracic Surgery, University of Massachusetts Medical Center and St. Vincent Hospital, Worcester, Massachusetts, USA
Address reprint requests to Dr Lee, Department of Cardiothoracic Surgery, University of Massachusetts Medical Center, 55 Lake Ave N, Worcester, MA 01655-0304
e-mail: smtp.k.lee{at}banyan.ummed.edu
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Abstract
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A large left ventricular fibroma was encountered perioperatively for what was presumed to be a sealed ventricular rupture after thrombolytic therapy for an acute myocardial infarction. We review the pertinent literature concerning the diagnosis of ventricular rupture and this rare benign tumor of the heart.
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Introduction
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Cardiac fibroma is a rare benign solitary tumor of the heart that occurs most commonly in the left ventricle or the interventricular septum. It is a congenital tumor most often found in infancy and adolescence, and less frequently in adults. Presentation is usually with conduction disturbances, congestive heart failure, chest pain, or sudden death. We present a case of an asymptomatic left ventricular fibroma encountered as an incidental finding after myocardial infarction and thrombolytic therapy, thought to be the setting for a sealed myocardial rupture.
A 44-year-old man with a family history of coronary artery disease was transferred to our institution after an anterolateral myocardial infarction 24 hours after the onset of chest pain. Thrombolytic therapy had been given 6 hours before admission. Results of serial electrocardiograms and elevated cardiac isoenzymes were consistent with a diagnosis of anterolateral myocardial infarction. Initial echocardiogram revealed a small to moderate sized pericardial effusion and extensive anterolateral left ventricular akinesis, over which lay a large echogenic density, thought most likely to indicate thrombus. Cardiac catheterization revealed the following stenoses: 80% proximal left anterior descending coronary artery, with residual intraluminal thrombus; 75% proximal obtuse marginal; and 90% distal right coronary. Left ventriculography found apical dyskinesis and anterolateral akinesis with an overall ejection fraction of 40% and the possibility of endocardial discontinuity. Follow-up echocardiography suggested an intramyocardial dissection and a sealed myocardial rupture (Fig 1). The presumptive diagnosis was postinfarction intramyocardial dissection and sealed ventricular rupture with impending cardiac tamponade.
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Fig 1. Transthoracic echocardiogram interpreted as revealing disruption of endocardium and intramyocardial dissection (arrow).
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An urgent operation was done on the third hospital day. Pericardiotomy released 150 mL of clear yellow fluid under moderate pressure, whereas blood had been expected. After cardiopulmonary bypass was begun, a large, firm, white mass was found on the lateral wall of the left ventricle, approximately 8 x 6 x 5 cm (Fig 2). The infarcted area was clearly in the distribution of the left anterior descending coronary artery, whereas the bulk of the tumor was lateral to the obtuse marginal artery. Multiple needle biopsies and a wedge biopsy were submitted for frozen section; the mass was a benign fibroma, subsequently confirmed on permanent section. Triple bypass using vein segments to the left anterior descending, obtuse marginal, and posterior descending arteries was done, and he was weaned from cardiopulmonary bypass without difficulty. The postoperative period was uneventful, and he was discharged home on the fourth postoperative day. He remains asymptomatic and continues to work 14 months after discharge and is being followed up closely for development of symptoms.
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Fig 2. Left ventricular fibroma on lateral wall. Biopsy site includes thinned myocardium (arrow). Patient head at top.
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Comment
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Cardiac fibroma is a rare congenital benign tumor of the heart and is the second most common primary cardiac tumor after myxoma, the first successful resection of which was performed in 1962 [1]. The most frequent location is the left ventricle, followed by the interventricular septum, right ventricle, and right atrium [2]. Most patients are asymptomatic, with the tumor encountered at autopsy. Clinically it can present with congestive failure, arrhythmias, chest pain, or sudden death, with the latter presentation frequently the initial manifestation if the interventricular septum is involved [3]. In the present case, the occurrence of acute myocardial infarction together with pericardial effusion and possible intramyocardial dissection by echocardiogram and ventriculogram, early after thrombolytic therapy, led us to decide on urgent surgical intervention. Intramyocardial dissection and sealed ventricular rupture have been diagnosed with increasing frequency and successfully repaired recently using a variety of techniques. There is also evidence that thrombolytic therapy can accelerate cardiac rupture within 24 to 48 hours of infarction [4].
Successful resection of large ventricular fibromas has been reported but with a relatively high mortality rate of 23% overall, which increases to 28% for septal tumors and 50% for those at the base of the ventricle [3]. More recently, successful transplantation has been reported on patients with extensive cardiac fibromas, with long-term survival [5, 6]. Even with improved techniques and increasing experience, the operative mortality risk for excision is relatively high and perhaps prohibitive in the setting of an evolving infarction in an area apart from the tumor, as in this case. Therefore, we decided to do a biopsy and revascularize, especially considering the asymptomatic status of the patient and the size of the tumor.
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References
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Parks F.R., Jr, Adams F., Longmire W.R., Jr Successful excision of a left ventricular hamartoma. Report of a case. Circulation 1962;26:1316-1320.[Abstract/Free Full Text]
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Beghetti M., Haney I., Williams W.G., Mawson J., Freedom R.M., Gow R.M. Massive right ventricular fibroma treated with partial resection and a cavopulmonary shunt. Ann Thorac Surg 1996;62:882-884.[Abstract/Free Full Text]
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Parmley L.F., Salley R.K., Williams J.P., Head G.B. The clinical spectrum of cardiac fibroma with diagnostic and surgical considerations. Ann Thorac Surg 1988;45:455-465.[Abstract/Free Full Text]
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Becker R.C., Gore J.M., Lambrew C., et al. A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction. J Am Coll Cardiol 1996;27:1321-1326.[Medline]
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Goldstein D.J., Oz M.C., Rose E.A., Fisher P., Michler R.E. Experience with heart transplantation for cardiac tumors. J Heart Lung Transplant 1995;14:382-386.[Medline]
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Jamieson S.W., Gaudiani V.A., Reitz B.A., Oyer P.E., Stinson E.B., Shumway N.E. Operative treatment of an unresectable tumor of the left ventricle. J Thorac Cardiovasc Surg 1981;81:797-799.[Abstract]
Accepted for publication January 18, 1999.
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M. Goel, R. Malhotra, V. Kohli, M. Mishra, S. Jain, Y. Mehta, and N. Trehan
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September 1, 2003;
11(3):
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[Abstract]
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Abstract
Introduction
