Ann Thorac Surg 2001;71:2022-2024
© 2001 The Society of Thoracic Surgeons
Case report
Organized thrombus of the tricuspid valve mimicking valvular tumor
Hiroaki Konishi, MDa,
Minoru Fukuda, MDa,
Morito Kato, MDa,
Yoshio Misawa, MDa,
Katsuo Fuse, MDa
a Department of Thoracic and Cardiovascular Surgery, Jichi Medical School, Tochigi, Japan
Accepted for publication April 25, 2000.
Address reprint requests to Dr Konishi, Department of Thoracic and Cardiovascular Surgery, Jichi Medical School, 3311-1 Yakushiji, Minamikawachi, Kawachigun, Tochigi 329-0498, Japan
e-mail: tcvhiro{at}jichi.ac.jp
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Abstract
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We report on a case of organized thrombus of the tricuspid valve mimicking a valve tumor. Preoperative transesophageal echocardiography showed the mass to have originated from the septal leaflet of the tricuspid valve. A pouch of the tricuspid valve and a ventricular septal defect were observed perioperatively, with the mass attached to the septal leaflet. Histologic examination revealed the mass to be an organized thrombus without tumor components.
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Introduction
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Cardiac valve tumors are rare, accounting for only approximately 10% of all primary cardiac tumors [1]. Most are asymptomatic and are diagnosed incidentally [2]. The most common histologic type is the papillary fibroelastoma. In the case of the tricuspid valve tumor, congestive heart failure is the main symptom, and two-dimensional echocardiography and transesophageal echocardiography are very useful for its diagnosis [3]. We encountered an organized thrombus of the tricuspid valve mimicking a valve tumor with a tricuspid valve pouch [4] and a ventricular septal defect (VSD).
A 23-year-old woman was referred to us in July 1998 for treatment of a suspected right ventricular tumor. She had first been hospitalized in December 1994 because of a common cold; at that time, she was diagnosed by echocardiography with mild mitral regurgitation due to mitral valve prolapse. A few months later two-dimensional echocardiography demonstrated an asymptomatic right ventricular tumor with calcification. By August 1998, the size of the tumor had increased from 20 mm to 25 mm, and she was referred to us for possible resection. Based on magnetic resonance imaging, our radiologist suspected a fibroma of the right ventricle (Fig 1). Transesophageal echocardiography showed the mass to be 25 mm in diameter and attached to the septal leaflet of the tricuspid valve (Fig 2). No other abnormalities were detected. We decided to resect the mass because of the enlargement and to prevent of pulmonary embolism.
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Fig 1. Preoperative magnetic resonance imaging scan in sagittal section showing tumor of the right ventricle.
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Fig 2. Transesophageal echocardiographic imaging. The arrow marks the tumor attached to the septal leaflet of the tricuspid valve. (RA = right atrium; RV = right ventricle; LV = left ventricle.)
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Cardiopulmonary bypass was established, and the right atrium was opened. The mass was attached to the septal leaflet of the tricuspid valve without a stem (Fig 3). Its actual size was 10 mm in diameter. The surface was yellowish-white and smooth, but the mass itself was elastically hard. It was resected with a part of the septal leaflet. After the mass was removed, a VSD was apparent. The diameter of the VSD was 8 mm, and shunt flow through the VSD was obstructed by the septal leaflet and valvular mass. It was the pouch of the tricuspid valve with the valvular mass. The mass was located on the right-heart side of the valve. It was resected, including a part of the septal leaflet, and the tricuspid valve was repaired. By means of a surgical patch, the VSD was closed. The patient was weaned easily from bypass and recovered uneventfully. Postoperative echocardiography demonstrated no regurgitation of the tricuspid valve and no VSD shunt flow. For 6 months after surgery, a low dose of aspirin was administered for short-term anticoagulation therapy. The 1-year follow-up showed no evidence of pulmonary embolism and tricuspid regurgitation.
Histopathological examination showed that the tumor was completely isolated from the valvular components and consisted of an organized thrombus with calcification (Fig 4). There was no tumorigenesis and also no evidence of endocarditis in the specimen.
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Fig 4. Histologic study of tumor and the tricuspid valve. On the left is the tumor (organized thrombus), and on the right is the valvular component. (Hematoxylin and eosin; x10.)
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Comment
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Cardiac valve tumors are rare and usually asymptomatic. Most cases of tricuspid valve tumor are diagnosed because of congestive heart failure. Two-dimensional echocardiography and transesophageal echocardiography are useful in detecting valve tumors. In our case, the tumor was initially identified as a right ventricular mass originating from the ventricular septum, but transesophageal echocardiography showed the tumor originating in the septal leaflet of the tricuspid valve. In a previous review, Edwards and colleagues [1] reported 73% of all valvular tumors to be papillary fibroelastomas. However, in our case there was neither pedicle nor any papillary fronds, which are detectable and essential for noninvasive diagnosis of a papillary fibroelastoma [5]. On the basis of magnetic resonance imaging, our radiologist strongly suspected that our patient’s cardiac mass was a fibroma, and preoperative in vivo diagnosis of this tumor was unclear.
Operative findings differed from preoperative diagnosis. The intracardiac mass was not a tumor but rather an organized thrombus attached to the edge of the valvular leaflet on the right-heart side with the pouch of the tricuspid valve (Fig 5). Upon removal of the mass, VSD was apparent. There are many reports about VSD with tricuspid pouch or aneurysm of the membranous ventricular septum, but a case such as ours, involving valvular tumor accompanied by VSD and tricuspid pouch, is quite unusual. The reason for the thrombus on the leaflet is not clear, but the pouch of the tricuspid valve due to VSD and turbulence could have produced stagnation of the blood flow around the pouch of the septal leaflet in the tricuspid valve, causing subsequent thrombus formation. Neither two-dimensional echocardiography nor transesophageal echocardiography detected the VSD or the jet flow because the thrombus was large enough to fill the septal defect and to prevent shunt flow from the left to right ventricle.
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Fig 5. Our case and a pouch of the tricuspid valve. (MS = mitral stenosis; RA = right atrium; RV = right ventricle; T = tumor; TV = tricuspid valve; VSD = ventricular septal defect.)
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Regarding perioperative treatment, even though we could radiologically differentiate the valvular mass from a tumor, it was necessary to explore the intracardiac mass surgically. Such masses should be examined surgically because of the possibility of embolism [6].
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References
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Edwards F.H., Hale D., Cohen A., Thompson L., Pezzella T., Virmani R. Primary cardiac valve tumors. Ann Thorac Surg 1991;52:1127-1131.[Abstract]
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LiMandri G., Homma S., DiTullio M.R., et al. Detection of multiple papillary fibroelastomas of the tricuspid valve by transesophageal echocardiography. J Am Soc Echocardiogr 1994;7:315-317.[Medline]
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Hamby R.I., Raia F., Apiado O. Aneurysm of the pars membranacea: report of three adult cases and a review of the literature. Am Heart J 1970;79:688-689.[Medline]
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Lund G.K., Schröder S., Koschyk D.H., Nienaber C.A. Echocardiographic diagnosis of papillary fibroelastoma of the mitral and tricuspid valve apparatus. Clin Cardiol 1997;20:175-177.[Medline]
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Howard R.A., Aldea G.S., Shapira O.M., Kasznica J.M., Davidoff R. Papillary fibroelastoma: increasing recognition of a surgical disease. Ann Thorac Surg 1999;68:1881-1885.[Abstract/Free Full Text]
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Abstract
Introduction
