Ann Thorac Surg 2008;85:315-317. doi:10.1016/j.athoracsur.2007.06.047
© 2008 The Society of Thoracic Surgeons
Case Reports
Unusual Tumor in the Left Ventricular Outflow Tract
Aref Amiri, MD,
Evgenij V. Potapov, MD*,
Michele Musci, MD,
Hans B. Lehmkuhl, MD,
Roland Hetzer, MD, PhD
Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
Accepted for publication June 5, 2007.
* Address correspondence to Dr Potapov, Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, Berlin, 13353, Germany (Email: potapov{at}dhzb.de).
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Abstract
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We report an unusual case of a pseudocyst in the left ventricular outflow tract in a 58-year-old woman. The cyst was successfully resected by a transatrial approach.
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Introduction
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Resection of a cardiac tumor was first performed in 1951, when Maurer [1] successfully removed an epicardial lipoma. In 1954 extracorporeal circulation enabled Crafoord [2] to successfully excise a left atrial myxoma [2]. Autopsy findings have shown that the prevalence of cardiac tumors range from 0.0017% to 0.28% [3]. Most of these are atrial myxomas followed by malignant tumors of primary cardiac or metastatic origin. Left ventricular cystic formations are rare. Clinical manifestations include arrhythmia and syncopal episodes. Beside rare pseudocysts, cystic formations are mostly blood cysts, bronchogenic cysts, hydatid cysts, or cyst-like thrombi.
Surgery should be performed as soon as the diagnosis is confirmed. The rationale for resection of all cardiac tumors is not unequivocally clear. The decision for operation is easy to make for symptomatic tumors, as in our case, and asymptomatic left-sided tumors of the heart if there is obstruction to blood flow or interference with valve function. Resection of apparently benign cardiac tumors is recommended to avoid potential complications such as cardiac failure, dysrhythmias, conduction disturbances, syncope, sudden cardiac death, or embolization that can be prevented by early resection. Other reasons are to rule out malignancy or diagnose a malignant tumor while it is still resectable.
We report an unusual case of a left ventricular pseudocyst arising from the left ventricle close to the chordae of the anterior mitral leaflet.
A 58-year-old woman presented with dyspnea on physical exercise. Her history included Wolff-Parkinson-White syndrome and chest burning for the past 6 months. She had normal blood pressure and pulse rate and no fever. Pulmonary auscultation was normal without rales. Cardiac auscultatory findings included a regular rhythm without thrills and the electrocardiogram showed sinus rhythm. The laboratory results were without any pathologic findings except for anemia (8.5 mg/dL).
Echocardiography performed in a peripheral hospital showed cystic formation in the left ventricle. A magnetic resonance imaging scan revealed a cystic mass adjunctive to the septum in the cavity of the left ventricular outflow tract (Fig 1). Echocardiographic evaluation showed prolapse into the left ventricular outflow tract, but without obstruction. The mean pressure difference was 18 mm Hg.
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Fig 1. Computed tomographic scan shows a cystic mass adjacent to the septum, prolapsing into the left ventricular outflow tract.
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The operation was performed by a median sternotomy using cardiopulmonary bypass by bi-caval cannulation. Antegrade cardioplegia was performed with crystalloid solution. After left atriotomy a smooth, spherical, glistening, fluid-filled structure measuring 2.4 x 2.5 x 3.2 cm was found behind the chordae of the anterior mitral leaflet, adjacent to the septum and prolapsing into the left ventricular outflow tract. The cystic mass was resected by a left atriotomy through the mitral valve (Fig 2) without mobilization of the anterior leaflet of the mitral valve.
The structure contained clear serous fluid with well-defined margins and had a smooth surface. Myocardial hypertrophy was absent and contractility of the left ventricle was normal. Heart valve morphology and function were also normal. Histologic examination of the cyst showed the walls to contain connective fibrous tissue without an inner epithelial layer. The patient had an uncomplicated postoperative recovery and was completely asymptomatic at her 6-year follow-up.
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Comment
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The present case shows unusual origin of a cystic mass in the left ventricle. Histologic evaluation showed the mass to be a pseudocyst filled with clear serous fluid. The origin of this pseudocyst may be from abscess after resorption of pus and healing, as a so-called "blood cyst" (ie, a cyst filled with blood), or as an endocardial hematoma progressing after resorption of blood particles formed a fluid-filled fibrous sack.
The patient had not had previous symptoms of inflammation, and there were no signs of destruction of the neighboring structures, as is usually the case in abscess formation. On the other hand, intracardiac blood-filled cysts are typically asymptomatic, usually congenital in origin, and they are commonly seen in infants. These cysts regress spontaneously in most of the affected patients and are rare in adults. These thin-walled cysts contain nonorganized blood or serosanguineous fluid and are lined by flattened, cobblestone-shaped endothelium and a thin layer of fibrous tissue [4], which was not the case here. We suggest that the intraoperative finding may be an old endocardial hematoma. However, because trauma and bleeding tendency were not present in the patient, its origin remains unclear.
The major concerns in the surgical treatment of cardiac tumors are to avoid complications during their removal and prevent recurrence. This may be achieved by an optimal approach and complete resection of the tumor. In the case of a hydatid cyst, opening of the cyst should be avoided. Therefore, in all cases of suspected cystic formation, the blood should be tested for echinococcus preoperatively.
Accurate preoperative information on the location, size, shape, mobility, and texture of a cyst, the number of chambers, and the portion attached is indispensable. Transesophageal echocardiography is essential for decision-making on the surgical approach, because it demonstrates the attached portion and the motion of the cyst, even when the stalk is unclear. In addition, the nature of the content of the cyst in terms of fluid or solid and homogeneous or not may be evaluated. Magnetic resonance imaging may supplement transesophageal echocardiography in detecting the extent of the lesion possibly invading the myocardium. The transaortic approach is the most appropriate for tumors in the left ventricular outflow tract and the transmitral approach for other locations. Talwalkar and colleagues reported on the use of a left atrial approach with mobilization of the anterior mitral valve leaflet to enhance exposure of the subvalvar region and facilitate excision of a left ventricular myxoma entangled within the chordal apparatus, lying between the anterolateral papillary muscle and the left ventricular wall [5]. In the present case, a transmitral approach was used for better visualization of the left ventricular cavity and safe access to the tumor, which might have involved the structures of the mitral valve. If that had been the case, mitral repair or replacement would have been an additional option. However, as seen intraoperatively, the tumor originated in the septum close to the anterior mitral leaflet, but the valve structures were intact. Although a separate transventricular approach may also be considered, this should be avoided as it could impair the function of the left ventricle.
In conclusion, diagnosis of the cystic formation should include transthoracic echocardiography and magnetic resonance imaging, which are also necessary to select the surgical approach, and echinococcosis should be ruled out by serological tests. Because of the risk for embolism and the need to rule out malignancy, excision is almost always indicated in an otherwise stable patient. During resection, care should be taken to remove the cyst completely without damaging it. In this rare case of a pseudocyst in the left ventricular outflow tract, resection through the transmitral approach was successful.
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Acknowledgments
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We are grateful to Anne M. Gale for her editorial assistance.
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References
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- Maurer ER. Successful removal of tumor of the heart J Thorac Surg 1952:479-485.
- Crafoord CI. Indications and results Minerva Cardioangiol 1955;1:159-162.[Medline]
- McAllister HAJ, Fenoglio JJ. Tumors of the cardiovascular system Atlas of tumor pathology. Washington, DC: Armed Forces Institute of Pathology; 1978. pp. 1-3.
- Roberts PF, Serra AJ, McNicholas KW, Shapira N, Lemole GM. Atrial blood cyst: a rare finding Ann Thorac Surg 1996;62:880-882.[Abstract/Free Full Text]
- Talwalkar NG, Livesay JJ, Treistman B, Lacle CE. Mobilization of the anterior mitral leaflet for excision of a left ventricular myxoma Ann Thorac Surg 1999;67:1476-1478.[Abstract/Free Full Text]
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Abstract
Introduction
