Ann Thorac Surg 2001;72:1739-1740
© 2001 The Society of Thoracic Surgeons
Case report
Sarcoma associated with silver coated mechanical heart valve prosthesis
Herko Grubitzsch, MD*a,
Hans-Georg Wollert, MDa,
Lothar Eckel, MDa
a Heart and Diabetes Centre Mecklenburg-Vorpommern, Clinic of Cardiothoracic and Vascular Surgery, Karlsburg, Germany
Accepted for publication December 28, 2000.
* Address reprint requests to Dr Grubitzsch, Herz- und Diabeteszentrum Mecklenburg-Vorpommern, Klinikum Karlsburg, Klinik für Herz-, Thorax- und Gefässchirurgie, Greifswalder Str 11 A, D-17495 Karlsburg, Germany
e-mail: grubitzsch{at}t-online.de
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Abstract
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Sarcomas can develop in association with foreign material (eg, from Dacron vascular prostheses). We report on a left atrial rhabdomyosarcoma that developed within 1 year of mitral valve replacement by a Silzone-coated St. Jude Medical mechanical heart valve. Tumor resection and redo valve replacement were done. Six months later the patient was alive, but an echocardiogram showed tumor recurrence. Although this is a single case, an association between heart valve prostheses and malignant tumors should be considered.
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Introduction
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Compared with metastatic tumors of the heart, primary cardiac tumors and sarcomas occur very rarely. Malignant soft tissue tumors can develop at sites of foreign material retained or implanted (eg, from metal or polymer foreign bodies or from Dacron vascular prostheses) [1–3]. However, sarcomas associated with mechanical heart valve prostheses, especially with silver-coated sewing cuffs, have not been described [4].
Cardiac tumors can be diagnosed incidentally or can become evident by a variety of symptoms. Their mass can obstruct intracardiac blood flow or interfere with valve function resulting in dyspnea. Local invasion can lead to arrhythmias or pericardial effusion with tamponade. Embolism of tumor tissue can cause ischemic events in pulmonary or systemic circulation.
The prognosis of patients with cardiac sarcomas is poor either from the extent of local spread and invasion or from frequent distant metastases. Many of these tumors cannot be resected completely. The recurrence rate is high. Nevertheless, surgery is indicated and usually supplemented by chemotherapy or radiotherapy. Although orthotopic heart transplantation is contraindicated in malignant diseases, it was done in selected cases, with varying results [5, 6].
We treated a patient with a left atrial rhabdomyosarcoma that developed within 1 year of mitral valve replacement by a Silzone-coated St. Jude Medical mechanical heart valve.
A 59-year-old woman presented with progressive dyspnea about 1 year after mitral valve replacement with a 29-mm Silzone-coated St. Jude Medical prosthesis (St. Jude Medical Heart Valve Division, St. Paul, MN). This operation was necessary because of mitral valve regurgitation caused by chronic endocarditis. Transesophageal echocardiography showed a huge left atrial mass almost completely obstructing the left atrial cavitiy leading to functional mitral stenosis. Valve function per se was not obstructed. According to transesophageal echocardiographic findings, the nature of this mass was suspected to be thrombogenic. However, intraoperatively the mass appeared as a malignant tumor with smooth surface but irregular structure and bleeding (Fig 1). In fact, two tumors originating from the former mitral valve commissures were present. Both masses were excised and the Silzone-coated prosthesis was removed. The resection of tumor tissue was as radical as possible with respect to the structures of the atrioventricular groove and macroscopically complete. A new 29-mm St. Jude Medical mechanical heart valve without the silver-coated sewing cuff was implanted.
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Fig 1. Intraoperative view of the larger portion of the left atrial rhabdomyosarcoma. The huge tumor mass with irregular structure and bleedings originated from one of the former commissures.
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Histologic examination revealed a rhabdomyosarcoma with high proliferative activity. Immunochemical staining was positive for desmin (muscle tissue marker), vimentin (mesenchymal marker), and MIB-1 (proliferation marker). Retrospective analysis of mitral valve cusps excised during the first operation found no evidence of malignant cells, suggesting tumor development within 1 year of prosthetic mitral valve replacement.
Her perioperative course was uneventful. Postoperative cerebral, thoracic, and abdominal computed tomographic scans showed absence of distant metastases. The patient left the hospital on the 20th postoperative day for follow-up radiotherapy. Six months later the patient was alive, but an isolated recurrent tumor was detected by echocardiogram. Heart transplantation was not considered because of the poor prognosis of rhabdomyosarcomas with a high risk of metastases and possible enhancement of tumor growth by immunosuppressive treatment.
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Comment
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Different types of sarcomas at sites of vascular prostheses have been reported [1–3]. Although short latency periods of a few months were seen occasionally, usually these sarcomas evolved over decades [1]. Thus, in the early and midterm postoperative period after mitral valve replacement thrombus formation is much more probable. However, if an anticoagulation protocol shows continuous effective anticoagulation, a tumor must be considered.
Although mechanical valve prostheses contain some synthetic materials identical to those in vascular prostheses, sarcomas associated with mechanical heart valves are extremely rare. Silzone-coated St. Jude Medical prostheses consist not only of plastic polymers, but also of elemental silver. Both materials are known to cause cancer in animals and humans [1–3]. Although silver coating is sufficient to prevent prosthetic valve endocarditis [4] the underlying mechanism of its antimicrobial efficacy might also lead to cancerogenicity.
This case cannot demonstrate any cause and effect relationship between the silver-coated valve prosthesis and the sarcoma. But the association in time as well as findings from other authors [1–3] suggest that implanted foreign material, in particular silver-coated polymers, should be considered potentially capable of inducing malignant tumors. Meanwhile Silzone-coated St. Jude Medical heart valve prostheses have been removed from the market. Nonetheless, to estimate whether there is a significant risk of tumor formation in association with these valves, follow-up studies of large patient groups are necessary.
Regarding treatment of cardiac sarcomas, we agree that heart transplantation should be contraindicated in malignant diseases. Although there are reports of successful transplantation [5], the risk of local or systemic recurrent disease is extremely high [6]. Furthermore, considering the shortage of donor organs, transplantation in these patients is ethically questionable.
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Acknowledgments
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We thank Prof R. Warzok, Pathologic Institute of the Ernst-Moritz-Arndt University Greifswald, for performing excellent immunochemical studies.
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References
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Jennings T.A., Peterson L., Axiotis C.A., Friedlaender G.E., Cooke R.A., Rosai J. Angiosarcoma associated with foreign body material. A report of three cases. Cancer 1988;62:2436-2444.[Medline]
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Weiss W.M., Riles T.S., Gouge T.H., Mizrachi H.H. Angiosarcoma at the site of a Dacron vascular prosthesis: a case report and review of the literature. J Vasc Surg 1991;14:87-91.[Medline]
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Ben-Izhak O., Vlodavsky E., Ofer A., Engel A., Nitecky S., Hoffman A. Epitheloid angiosarcoma associated with a Dacron vascular graft. Am J Surg Pathol 1999;23:1418-1422.[Medline]
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Brutel de la Riviere A., Dossche K.M., Birnbaum D.E., Hacker R. First clinical experience with a mechanical valve with silver coating. J Heart Valve Dis 2000;9:123-129.[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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Crespo M.G., Pulpon L.A., Pradas G., et al. Heart transplantation for cardiac angiosarcoma: should its indication be questioned?. J Heart Lung Transplant 1993;12:527-530.[Medline]
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Abstract
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