Ann Thorac Surg 2003;76:1305-1307
© 2003 The Society of Thoracic Surgeons
Case report
Successful resection of a symptomatic right ventricular lipoma
Sonja Schrepfer, MD*a,
Tobias Deuse, MDa,
Christian Detter, MDa,
Hendrik Treede, MDa,
Andreas Koops, MDb,
Dieter H. Boehm, MDa,
Stephan Willems, MDc,
François Lacour-Gayet, MDa,
Hermann Reichenspurner, MD, PhDa
a Department of Cardiovascular Surgery, Hamburg, Germany
b Department of Radiology, and Hamburg, Germany
c Department of Cardiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
Accepted for publication March 4, 2003.
* Address reprint requests to Dr Schrepfer, Department of Cardiovascular Surgery, University Hospital Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
e-mail: tobias.deuse{at}t-online.de
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Abstract
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We report the case of a 31-year-old woman with a 4-year history of recurrent palpitations, presenting with an increased frequency of paroxysms caused by ventricular tachycardias during pregnancy. A cardiac tumor of unknown origin infiltrating the right ventricle was diagnosed. Three weeks after prophylactic abrasion the tumor was totally excised with the use of cardiopulmonary bypass including restoration of the right ventricular wall and the tricuspid valve. Histology confirmed diagnosis of a benign cardiac lipoma. The postoperative course was uneventful and the patient was discharged 7 days after surgery. There was no episode of ventricular tachycardias during the 6-month follow-up.
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Introduction
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Primary cardiac tumors are rare [1] and only few cause symptoms. Although 75% of primary tumors are histologically benign [2], clinical manifestations are sometimes malignant as a result of valvular obstruction, intracavitary obstruction, peripheral embolization, and serious arrhythmia [3].
The most common arrhythmia caused by cardiac tumors is atrial fibrillation. Ventricular tachycardia is caused by damage to the myocardium or conduction system. It is most commonly observed with rhabdomyoma, fibroma, teratoma, and fibroelastoma located within the myocardium, but it also has been reported for lipoma [3]. Bradyarrhythmia, often caused by damage to the atrioventricular node has not been reported for lipoma yet. Some arrhythmias have paroxysmal occurrence and can cause sudden death.
In addition, there have been reports of cardiac lipomas causing cardiac dysfunction by compression of the left ventricle, valvular dysfunction, and peripheral embolization [4]. Thus surgical resection should be performed for symptomatic lipomas. Depending on the symptomatic, small benign tumors can be enucleated by peeling the tumor out of its capsule, others must be totally resected.
We report on a 31-year-old woman with a 4-year history of recurrent paroxysms of tachycardias with unknown origin. However when the patient presented with increasing frequency of tachycardic episodes during the past few weeks, a pregnancy in the fourteenth week of gestation was confirmed. The pattern of the tachycardia documented in the surface electrocardiogram with a rate of 190 beats per minute was suggestive for a right ventricular origin close to the outflow tract. A transthoracic echocardiogram, a computer tomography, and a magnetic resonance tomography revealed a large tumor-mass in the right ventricular wall (Fig 1)
extending 4.5 to 5 cm in diameter. It was located subepicardially with no clear demarcation to the right ventricular myocardium. Coronary angiography revealed no compression of the right coronary artery by the underlying tumor mass and showed no aberrant tumor vessels.
Because of the potential malignancy of the tumor infiltrating the right ventricular wall and the unclear extent of the operation, an interruption of pregnancy was performed in the sixteenth week of gestation. Three weeks later, surgical resection was planned with the backup of a right ventricular assist device (Thoratec VAD [Thoratec Corporation, Pleasanton, CA]). The operation was then performed on extracorporeal circulation by cannulation of the aorta ascendens and both venae cavae. The heart was arrested using antegrade cardioplegia (Custodiol solution [Custodiol, Alsbach-Hähnlein, Germany]). The body temperature was lowered to 30°C. After opening of the pericardium, the tumor became apparent in the anterior right ventricular wall, extending from the atrioventricular groove underneath the right coronary artery to the right ventricular outflow tract and dorsally to near the aortic valve. Three biopsies were taken and revealed exclusively mature benign adipose tissue in frozen sections. After transverse opening of the right atrium, a finger was inserted into the heart and the tumor was palpated under the tricuspid valve with direct contact to the tricuspid annulus. The right coronary artery, running across the tumor mass was isolated and mobilized, and minor side branches were divided. A plane was dissected between the tumor and the right ventricular myocardium. Trabeculae and papillary muscles were preserved. The tricuspid valve annulus was carefully detached from the tumor wall. Furthermore, the tumor was dissected dorsally to the aortic valve. The tumor mass was totally excised, leaving a defect of 3.5 x 4 cm extending from the right atrium to the right ventricle (Fig 2).
The tumor did not reach the coronary sinus. The defect in the right ventricular wall was closed with a patch of autologous glutaraldehyde-fixed pericardium and the tricuspid valve annulus was reattached to the patch. During reperfusion, the right coronary artery was carefully inspected. There was no bleeding, and there was a good palpable pulse. After an aortic cross-clamp time of 65 minutes, the patient was weaned from cardiopulmonary bypass without any signs of right-sided cardiac failure. Intraoperative transesophageal echocardiography revealed good right ventricular function with only mild tricuspid valve insufficiency. Histology confirmed the diagnosis of a benign, cardiac lipoma. The patient had an uneventful postoperative course and was discharged 7 days after the operation. There was no further episode of ventricular tachycardias during the 6-month follow-up.
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Fig 2. Intraoperative picture of the operation field showing the excised tumor mass and the defect in the right ventricular wall. The right coronary artery is isolated.
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Comment
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Intramyocardial lipomas are a known cause of ventricular arrhythmia, especially ventricular tachycardia. However, ventricular tachycardias have less frequently been reported than other benign tumors such as fibroelastoma, teratoma, or fibroma [3]. The tumor location within the myocardium rather than a tumor specific interaction with the conduction system is thought to be responsible for arrhythmia induction.
However, this is the first article to report an increase in ventricular tachycardia frequency during pregnancy. Lowered serum electrolyte levels cause by hemodilution, increased cardiac output, or hormonal changes during pregnancy may support arrhythmia induction in this setting.
For ventricular cavity closure, a patch of autologous pericardium should be used, and for large defects cardiomyoplasty can be performed [5]. Surgery should be done by organizing the backup of a ventricular support system in case of extensive tumor excision resulting in ventricular dysfunction.
Partial tumor resection can be successful to relieve symptoms caused by tumor compression. However, the risk for sudden death caused by ventricular arrhythmia probably remains. Thus the tumor was totally excised and not just peeled out of its capsule.
Cardiac lipomas are rare and often present so insidiously that their diagnosis and therapy is significantly delayed. Although the long-term prognosis of asymptomatic lipomas is good, fatal courses have been reported for untreated symptomatic lipomas [6]. Therefore, if a lipoma is found to cause symptoms, indication for operation should be liberal in order to prevent potentially life-threatening complications.
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References
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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 Pathol Lab Med 1993;117:1027-1031.[Medline]
- Miralles A., Bracamonte L., Soncul H., et al. Cardiac tumors: clinical experience and surgical results in 74 patients. Ann Thorac Surg 1991;52:886-895.[Abstract/Free Full Text]
- Kusano K.F., Ohe T. Cardiac tumors that cause arrhythmias. Card Electrophys Rev 2002;6:174-177.
- Verkkala K., Kupari M., Maamies T., et al. Primary cardiac tumors–operative treatment of 20 patients. Thorac Cardiovasc Surg 1989;37:361-364.[Medline]
- Chachques J.C., Argyriadis P.G., Latremouille C., et al. Cardiomyoplasty: ventricular reconstruction after tumor resection. J Thorac Cardiovasc Surg 2002;123:889-894.[Abstract/Free Full Text]
- Ashar K., van Hoeven K.H. Fatal lipoma of the heart. Am J Cardiovasc Pathol 1992;4:85-90.[Medline]
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Abstract
Introduction
