Ann Thorac Surg 2001;71:2032-2034
© 2001 The Society of Thoracic Surgeons
Case report
Reconstruction of the left ventricle in a patient with cardiac hemangioma at the apex
Yasuko Tomizawa, MD, PhDa,
Masahiro Endo, MDa,
Hiroshi Nishida, MDa,
Chizuo Kikuchi, MDa,
Hitoshi Koyanagi, MDa
a Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
Accepted for publication April 19, 2000.
Address reprint requests to Dr Tomizawa, Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, 8-1 Kawada, Shinjuku, Tokyo l62-8666, Japan
e-mail: qyp03741{at}nifty.ne.jp
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Abstract
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Cardiac hemangiomas in the left ventricle are extremely rare. A 34-year-old woman, without symptoms, with a diagnosis of cardiac tumor at the apex of the left ventricle was referred to us. The tumor was surgically resected, and the diagnosis was hemangioma. The Jatene technique, originally introduced for left ventricular aneurysmectomy was excellent for repair after resection of a cardiac tumor at the apex.
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Introduction
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Cardiac hemangiomas are rare. In the review by McAllister [1] of 533 primary tumors and cysts of the heart and pericardium, hemangiomas comprised only 2.8%. Burke and Virmani [2] found fewer than 75 cases of hemangioma in the literature. Ventricular tumors are uncommon. In 45 reviewed cases of cardiac hemangioma, 12 were located in the left ventricle or ventricular septum and 11 in the right ventricle [2]. Cardiac hemangiomas are not always clinically benign. When wide cardiac resection is necessary, based on the location of the cardiac tumor, thoughtful consideration of the reconstruction procedure is essential.
A 34-year-old woman was referred to our outpatient clinic without symptoms, with a diagnosis of cardiac tumor at the apex of the left ventricle. Myocardial biopsy had been done through a catheter, but no tumor tissue was obtained in the specimens. Her chest roentgenogram showed no specific changes. Her electrocardiogram (ECG) had small abnormal Q waves in II, III, and aVf and negative T waves in V3 to V6. The size of the tumor was 3.1 cm x 2.0 cm on echocardiography. Left ventriculography showed a filling defect at the apex and coronary angiography showed pooling and feeding arteries from the diagonal branch of the left coronary artery. The mass was vascular. Magnetic resonance imaging showed a mass at the left ventricular apex with greater enhancement than myocardium. No lymph node enlargement was detected by computed tomography in the mediastinum.
The patient was taken to the operating room. Median sternotomy was done under general anesthesia. No effusion was found in the pericardial cavity, and the heart was free of adhesion. The tumor was a mass 4 cm in diameter, and its surface was vascular (Fig 1A). Using cardiopulmonary bypass (CPB), under cardioplegic arrest with topical cooling, the tumor at the apex was resected. The tumor adjacent to the left ventricular cavity was white, and there was a clear borderline between the normal myocardium and the white tissue (Fig 1B). Cryosurgery was used on the remaining white tissue inside the cavity. An autologous pericardium-covered elliptical fabric vascular graft patch was made and inserted. Felt strips were placed around the cut edge of the ventricle for reinforcement (Fig 1C). The patch and strips were secured with mattress sutures (Fig 1D). Fibrin glue and oxygenated cellulose cotton were used to prevent oozing of blood. Macroscopically, the excised tumor was whitish without necrosis or bleeding. Microscopically, many small vessels, myocytes, sporadic adipose tissue, and elastic fibers were observed. The histologic diagnosis was hemangioma. Cardiac function promptly recovered postoperatively. The patient was discharged uneventfully.
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Fig 1. Operative view. (A) The tumor (T) was apex. (B) The left ventricular cavity (L) side of the tumor was white. (C) Felt strips were placed around the cut edge. An autologous pericardium-covered fabric patch and strips were secured with mattress sutures. To the right ventricle free wall, stitches were made from the patch to the ventricular septum (S) and then to the right ventricle wall. (D) A new apex was made. (R = right ventricular cavity.)
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Comment
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To diagnose a mass in the heart using echocardiography is not difficult. Recently, diagnosis of heart tumors in fetuses has been made possible by echocardiography, and in that study, cardiac tumors were present in 0.14% of pregnant women with abnormal findings on obstetric ultrasound [3]. However, differential diagnosis and histology between malignant and benign tumors can be achieved only by microscopic studies of specimens.
Surgery is the first choice of therapy in all patients with cardiac tumors. There are surgical reviews of primary cardiac tumors from all over the world [4], but most reports include only a single case of hemangioma because of its rarity. At cardiac tumor resection, the most common approach is median sternotomy; lateral thoracotomy is the second. Total resection using CPB, partial or incomplete resection with or without CPB, or simple biopsy under thoracoscopy is done depending on the anatomic location and extent of the tumor and the involvement of myocardium. In a review of 75 cardiac hemangiomas, at least 37 cases were surgically resected, and among them, 30 cases were excised completely [2]. In a review of 34 cases by Pigato and associates [4], follow-up information was available only in 47% of them.
The choice of procedure in cardiac wall reconstruction after resecting a tumor in the left ventricle is important, because heart failure can result from low cardiac output. Sometimes associated procedures, including coronary bypass grafting and valve replacement, are necessary. After linear closure of the ventriculotomy in myocardial infarction was introduced, Jatene [5] developed a technique to restore both overall global ventricle geometry and myocardial fiber orientation in the nonaneurysmal portion of the ventricle to their original morphologic states. It is essential to restore the normal geometry of the left ventricle as nearly as possible to its original state, because too great an area of resection, because of involvement of myocardium, and resulting heart failure can limit life expectancy and quality of life. Because it was possible to maintain the natural geometry, cardiac function was satisfactory in our case postoperatively.
Sudden death attributed to primary cardiac tumors occurred in 120 cases, including six hemangiomas, and 86% of those tumors were histologically benign [6]. Hemangiomas can rupture or spontaneously resolve [3]. Intracardiac tumors can precipitate conductive and hemodynamic abnormalities resulting in sudden death. Resectable benign cardiac tumors usually have a good prognosis, but unresectable benign tumors have a poor prognosis because of ventricular arrhythmias, sudden death, local progression, or systemic dissemination of the neoplastic process.
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References
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McAllister H. Tumors of the heart and pericardium. In: Silver M.D., ed. Cardiovascular pathology. New York: Churchill Livingstone, 1983:909-943.
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Burke A, Virmani R. Tumors of the heart and great vessels. In: Atlas of tumor pathology. 3rd series, fascicle 16. Washington, DC: Armed Forces Institute of Pathology, 1995:80–6.
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Holley D.G., Martin G.R., Brenner J.I., et al. Diagnosis and management of fetal cardiac tumors: a multicenter experience and review of published reports. J Am Coll Cardiol 1995;26:516-520.[Abstract]
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Pigato J.B., Subramanian V.A., McCaba J.C. Cardiac hemangioma. A case report and discussion. Texas Heart Inst J 1998;25:83-85.[Medline]
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Jatene A.D. Left ventricular aneurysmectomy. Resection or reconstruction. J Thorac Cardiovasc Surg 1985;89:321-331.[Medline]
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Cina S.J., Smialek J.E., Burke A.P., Virmani R., Hutchins G.M. Primary cardiac tumors causing sudden death: a review of the literature. Am J Forensic Med Pathol 1996;17:271-281.[Medline]
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Abstract
Introduction
