Ann Thorac Surg 2001;72:264-265
© 2001 The Society of Thoracic Surgeons
Case report
Varix of the heart
Jean-Paul Remadi, MDa,
Amar BenAmar, MDa,
Olivier Baron, MDa
a Cardiovascular and Thoracic Surgery Unit, Amiens Hospital, Amiens, France
Accepted for publication May 17, 2000.
Address reprint requests to Dr Remadi, Cardiovascular and Thoracic Surgery Unit, South Hospital, 80054 Amiens Cedex 1, France
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Abstract
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A 76-year-old patient was operated on for an asymptomatic primary tumor of the heart located in the right atrium. The tumor was detected during a preanesthetic check-up for a transurethral resection of a prostate adenoma, showing a 3/6 systolic murmur. The mass was resected. The postoperative course was uneventful but the histologic result was surprising: varix of the heart.
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Introduction
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Myxoma is the most frequent tumor of the heart, and varices are unusual primary tumors of the heart. We here present a case where the diagnosis was made through histology.
A male patient aged 76 years of age was schedulded for transurethral resection of a prostatic adenoma. During the preanesthetic check-up a 3/6 systolic murmur was detected. On the other hand, this patient was asymptomatic and had no specific previous history. Transesophageal echocardiography revealed a right intraatrial cystic mass (Fig 1), with small areas of intrasaccular calcium deposits. This mass induced a 2 to 3 grade tricuspid insufficiency with a prolapse into a slightly dilated right ventricle. The other heart cavities were normal with the left ventricular ejection fraction. A thoracic computed tomography (CT) scan confirmed the presence in the right atrium of a mobile mass with a 60-mm diameter without any arteriovenous flow.
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Fig 1. Transesophageal echocardiography revealed a right intraatrial cystic mass with small areas of intrasaccular calcium deposits. (T = tumor.)
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All serologic tests (including hydatidosis) were negative. At the end of the preoperative check-up, the diagnosis of a myxoma was the most probable. Because of the risks of tricuspid impaction and pulmonary embolism, the patient was operated on.
After routine median sternotomy, cardiopulmonary-bypass was set up between the aorta and both vena cava. The inferior vena cava cannula was inserted very low near to the diaphragm to be as far away as possible from the tumor. Likewise, the superior vena cava cannula was inserted very high in the superior vena cava.
After aortic cross clamping and induction of a cold crystalloid cardioplegia at 4°C, right atriotomy was performed. A brief circulatory arrest was allowed to drain the operative field, locate the implantation basis of the tumor, and therefore safely snare the inferior vena cava. This implantation basis was located under the ovalis fossa of the heart, at the same distance of the inferior vena cava and coronary sinus. This 5 to 7 cm tumor had a pink cystic aspect and palpation revealed hard particles of a few millimeters in size. Resection was performed in one piece and the implantation basis was buried by a continuous suture. The tricuspid valve was normal and right ventricular examination was negative. The anatomopathologic examination confirmed a 6-cm long tissue pouch with a thin and transparent wall containing small yellowish masses appended to this wall (Fig 2). Histology diagnosis was varix of the heart containing true phleboliths. Eighteen months after this operation, the patient was asymptomatic, in sinus rhythm, and control echocardiography was utterly normal.
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Comment
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According to the literature, the incidence of heart tumors varies between 0.02% and 0.056% [1, 2]. Primary heart tumors are most often benign and mainly consist of myxoma [3]. The left and right atria are the most frequently affected sites. Among these benign tumors, the incidence of heart varices is evaluated at 0.007% [3]. Therefore, cases reported in the literature are extremely rare [4, 5]. These varices develop at the expense of small veins located on the inferior part of the ovalis fossa. Rare cases of intraventricular varices have been reported [3]. The main histologic differential diagnoses are blood cysts and hemangioma [3]. These varices are most often unifocal [3]. Resection of these tumors is hightly recommended, considering the risks of prolapse into the right ventricle and tricuspid valve obstruction.
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References
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Reynen K. Frequency of primary tumors of the heart. Am J Cardiol 1996;77:107.[Medline]
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Lam K.Y., Dickens P., Chan A.C. Tumors of the heart. A 20 year experience with a review of 12,485 consecutive autopsies. Arch Path Lab Med 1993;117:1027-1031.
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Burke A., Virmani R. Atlas of tumors pathology. Tumors of the heart and great vessels. Washington, DC: American Registry of Pathology, 1996:78-82.
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Harrity P.J., Tazelaar H.D., Edwards W.D., Orzulak T.A., Freeman W.K. Intra-cardiac varices of the right atrium. Int J Carrdiology 1995;48:177-181.
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Salas Valien J.S., Ribas Arino M.T., Palau Benavides M.T., Gonzalez Moran M.A. Varix of the heart causing outflow tract obstruction. Histol Histopathology 1991;6:439-442.
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Abstract
Introduction
