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Extra cardiac tumor misdiagnosed as a left atrial myxoma.

Choi K, Jung D, Hong SW, Jeon Y, Kim SO - Korean J Anesthesiol (2014)

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Daegu, Korea.

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The anesthetic management proceeded uneventfully, with 0.5% sevoflurane, and continuous infusion of fentanyl with rocuronium was administered... Prior to CPB initiation, the TEE examinations detected a mobile mass between the LAA and left pulmonary vein, which confirmed the echocardiographic findings of the preoperative TTE examinations (Fig. 1B)... Conversely, the TEE revealed that the mass was still located in the LA... It was concluded that the mass was of an extra-cardiac origin; subsequently, re-weaning from the CPB was performed uneventfully... A postoperative chest CT only revealed mural thrombi at the anterior aspect of the LA; however, the LAA was not observed... Conversely, the postoperative TTE did not reveal any mass in the LA cavity, and an ejection fraction of 46% was recorded... Histopathological analysis indicated an undifferentiated epithelioid sarcoma, which appeared to be a malignant fibrous histiocytoma (MFH) upon microscopy... Conversely, MFHs commonly originate near the pulmonary veins or the LAA... In the present case, upon TEE examination prior to CPB, the mass was observed in the LAA, extending from the left upper pulmonary vein... A more observant diagnosis, based on the TEE findings at this point, might have reduced the unnecessary expenses... After rewarming, another search was conducted for the remnant mass through a left atriotomy, however, no tumor was found within the cavity... This might also be explained by the extra-cardiac origin nature of the mass... This case confirms that tumors of extra-cardiac origin may also occur, and hence, this possibility should be considered when the location or shape of the mass lesion is unusual on pre- CPB TEE examinations, or when remnant mass-like lesions are noted on post-CPB TEE examinations during LA myxoma surgeries.

No MeSH data available.


Computerized tomography of the chest revealed a cardiac mass (T) at the anterior portion of the left atrium (A). Transesophageal echocardiographic, midesophageal two-chamber view prior to the initiation of cardiopulmonary bypass. The mass (★) was observed in the left atrial appendage (B). Transesophageal echocardiographic, midesophageal two-chamber view after cardiopulmonary bypass. The mass (★) was still observed in the left atrial appendage (C). LA: Left atrium, LV: Left ventricle.
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Figure 1: Computerized tomography of the chest revealed a cardiac mass (T) at the anterior portion of the left atrium (A). Transesophageal echocardiographic, midesophageal two-chamber view prior to the initiation of cardiopulmonary bypass. The mass (★) was observed in the left atrial appendage (B). Transesophageal echocardiographic, midesophageal two-chamber view after cardiopulmonary bypass. The mass (★) was still observed in the left atrial appendage (C). LA: Left atrium, LV: Left ventricle.

Mentions: A 3 cm mass or thrombus-like lesion within the LA cavity was detected incidentally, upon chest computed tomography (CT) in a 51-year-old woman (Fig. 1A). A subsequent transthoracic echocardiographic examination (TTE) also revealed the presence of an echogenic mass, with characteristic features of a myxoma in the left atrial appendage (LAA), and concomitant mild mitral valve regurgitation, but normal ejection fraction (59%). An operation, involving median sternotomy under the general anesthesia, including minimally invasive techniques and a cardiopulmonary bypass (CPB), was performed with the aim of resecting the presumed LA myxoma. The anesthetic management proceeded uneventfully, with 0.5% sevoflurane, and continuous infusion of fentanyl with rocuronium was administered. Prior to CPB initiation, the TEE examinations detected a mobile mass between the LAA and left pulmonary vein, which confirmed the echocardiographic findings of the preoperative TTE examinations (Fig. 1B). The surgery aimed to remove the mass, with concomitant mitral valvuloplasty; the excised mass (2 × 2 cm in size) was gelatinous and mobile, and was attached to the wall between the LAA and left upper pulmonary vein. However, after rewarming and repairing the left atriotomy, the post-CPB TEE examinations revealed that the tumor was still present within the LA cavity (Fig. 1C). After discussion with the surgeons, the mass was inspected once more via a left atriotomy; however, visual inspection did not indicate any tumor within the cavity. Conversely, the TEE revealed that the mass was still located in the LA. It was concluded that the mass was of an extra-cardiac origin; subsequently, re-weaning from the CPB was performed uneventfully. The patient awoke 4 hours after arriving at the intensive care unit, with no neurological deficits; she was discharged uneventfully on POD 15. A postoperative chest CT only revealed mural thrombi at the anterior aspect of the LA; however, the LAA was not observed. Conversely, the postoperative TTE did not reveal any mass in the LA cavity, and an ejection fraction of 46% was recorded. Histopathological analysis indicated an undifferentiated epithelioid sarcoma, which appeared to be a malignant fibrous histiocytoma (MFH) upon microscopy. The metastatic workup was negative, and the patient subsequently underwent chemotherapy.


Extra cardiac tumor misdiagnosed as a left atrial myxoma.

Choi K, Jung D, Hong SW, Jeon Y, Kim SO - Korean J Anesthesiol (2014)

Computerized tomography of the chest revealed a cardiac mass (T) at the anterior portion of the left atrium (A). Transesophageal echocardiographic, midesophageal two-chamber view prior to the initiation of cardiopulmonary bypass. The mass (★) was observed in the left atrial appendage (B). Transesophageal echocardiographic, midesophageal two-chamber view after cardiopulmonary bypass. The mass (★) was still observed in the left atrial appendage (C). LA: Left atrium, LV: Left ventricle.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4295987&req=5

Figure 1: Computerized tomography of the chest revealed a cardiac mass (T) at the anterior portion of the left atrium (A). Transesophageal echocardiographic, midesophageal two-chamber view prior to the initiation of cardiopulmonary bypass. The mass (★) was observed in the left atrial appendage (B). Transesophageal echocardiographic, midesophageal two-chamber view after cardiopulmonary bypass. The mass (★) was still observed in the left atrial appendage (C). LA: Left atrium, LV: Left ventricle.
Mentions: A 3 cm mass or thrombus-like lesion within the LA cavity was detected incidentally, upon chest computed tomography (CT) in a 51-year-old woman (Fig. 1A). A subsequent transthoracic echocardiographic examination (TTE) also revealed the presence of an echogenic mass, with characteristic features of a myxoma in the left atrial appendage (LAA), and concomitant mild mitral valve regurgitation, but normal ejection fraction (59%). An operation, involving median sternotomy under the general anesthesia, including minimally invasive techniques and a cardiopulmonary bypass (CPB), was performed with the aim of resecting the presumed LA myxoma. The anesthetic management proceeded uneventfully, with 0.5% sevoflurane, and continuous infusion of fentanyl with rocuronium was administered. Prior to CPB initiation, the TEE examinations detected a mobile mass between the LAA and left pulmonary vein, which confirmed the echocardiographic findings of the preoperative TTE examinations (Fig. 1B). The surgery aimed to remove the mass, with concomitant mitral valvuloplasty; the excised mass (2 × 2 cm in size) was gelatinous and mobile, and was attached to the wall between the LAA and left upper pulmonary vein. However, after rewarming and repairing the left atriotomy, the post-CPB TEE examinations revealed that the tumor was still present within the LA cavity (Fig. 1C). After discussion with the surgeons, the mass was inspected once more via a left atriotomy; however, visual inspection did not indicate any tumor within the cavity. Conversely, the TEE revealed that the mass was still located in the LA. It was concluded that the mass was of an extra-cardiac origin; subsequently, re-weaning from the CPB was performed uneventfully. The patient awoke 4 hours after arriving at the intensive care unit, with no neurological deficits; she was discharged uneventfully on POD 15. A postoperative chest CT only revealed mural thrombi at the anterior aspect of the LA; however, the LAA was not observed. Conversely, the postoperative TTE did not reveal any mass in the LA cavity, and an ejection fraction of 46% was recorded. Histopathological analysis indicated an undifferentiated epithelioid sarcoma, which appeared to be a malignant fibrous histiocytoma (MFH) upon microscopy. The metastatic workup was negative, and the patient subsequently underwent chemotherapy.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Daegu, Korea.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

The anesthetic management proceeded uneventfully, with 0.5% sevoflurane, and continuous infusion of fentanyl with rocuronium was administered... Prior to CPB initiation, the TEE examinations detected a mobile mass between the LAA and left pulmonary vein, which confirmed the echocardiographic findings of the preoperative TTE examinations (Fig. 1B)... Conversely, the TEE revealed that the mass was still located in the LA... It was concluded that the mass was of an extra-cardiac origin; subsequently, re-weaning from the CPB was performed uneventfully... A postoperative chest CT only revealed mural thrombi at the anterior aspect of the LA; however, the LAA was not observed... Conversely, the postoperative TTE did not reveal any mass in the LA cavity, and an ejection fraction of 46% was recorded... Histopathological analysis indicated an undifferentiated epithelioid sarcoma, which appeared to be a malignant fibrous histiocytoma (MFH) upon microscopy... Conversely, MFHs commonly originate near the pulmonary veins or the LAA... In the present case, upon TEE examination prior to CPB, the mass was observed in the LAA, extending from the left upper pulmonary vein... A more observant diagnosis, based on the TEE findings at this point, might have reduced the unnecessary expenses... After rewarming, another search was conducted for the remnant mass through a left atriotomy, however, no tumor was found within the cavity... This might also be explained by the extra-cardiac origin nature of the mass... This case confirms that tumors of extra-cardiac origin may also occur, and hence, this possibility should be considered when the location or shape of the mass lesion is unusual on pre- CPB TEE examinations, or when remnant mass-like lesions are noted on post-CPB TEE examinations during LA myxoma surgeries.

No MeSH data available.