Mortality and embolic potential of cardiac tumors

Percutaneous Intracardiac Mass Extraction in High Surgical-Risk Patients

Large intracardiac masses including tumors, thrombi, and vegetations result in detrimental embolic or obstructive sequelae and present a management dilemma. Open heart surgery, the traditional approach, may not be an option for many patients with a prohibitive surgical risk due to multiple comorbidities. Recently, percutaneous options have emerged with reported success in extracting such intracardiac masses. A 42-year-old female with history of advanced primary sclerosing cholangitis with decompensated liver cirrhosis causing ascites and variceal bleed presented to the emergency department with fatigue, subjective fevers, chills and melena. Laboratory results revealed neutrophil-predominant leukocytosis and normocytic anemia, and blood cultures were positive for Candida albicans. Electrocardiography showed sinus tachycardia. Chest X-ray was unremarkable. She underwent packed red blood cell transfusion and esophageal banding for variceal bleeding. Transthoracic echocardiogram revealed normal left ventricular ejection fraction and no wall motion abnormalities. A right atrial mobile mass measuring approximately 1.0 × 3.0 cm was noted. Multidisciplinary heart team discussion concluded that while the mass posed a high embolic risk, the patient had a prohibitive risk for surgical intervention. Successful percutaneous removal of the mass using Penumbra system device (Penumbra Incorporated, Alameda, CA) was accomplished. This case report details the procedure and outcomes, as well as presents a literature review.

A Rapidly Growing Cardiac Mass-Malignant or Benign?

•Rapidly growing cardiac tumors can be benign or malignant. •Rarely, cardiac myxomas may grow rapidly, causing heart failure or obstructive symptoms. •Echocardiography remains the first-line imaging for cardiac tumors. •Multimodality imaging with CCT, CMR, and PET may aid in diagnosis.

Clinical Characteristics and Surgical Outcomes of Right Heart Myxoma and Its Comparison with Left Heart Myxoma: A Single-Center Retrospective Study

BACKGROUND

Cardiac myxomas are commonly located in the left atrium but rarely affect the right side of the heart. We retrospectively analyzed 28 patients receiving surgical treatment for right heart myxomas at our center and aimed to summarize the clinical features and surgical outcomes of right heart myxomas.

METHODS

Between May 2001 and June 2022, 244 patients with sporadic cardiac myxomas underwent complete surgical resection. Twenty-eight patients (28/244, 11.48%) were right heart myxomas. Among the 28 right heart myxoma cases, 25 underwent median sternotomy and 3 underwent robotic or total thoracoscopic procedures. The clinical features, operative information, and follow-up data of right heart myxoma were comprehensively reviewed, and clinical characteristics between right heart myxoma and left heart myxoma were also compared.

RESULTS

A significant difference was noted in sex between right heart myxoma and left heart myxoma (P <.05). Right heart myxoma had a higher asymptomatic rate (17.86% vs. 3.70%, P =.007) and a lower embolization rate (3.57% vs. 30.09%, P =.003) than left heart myxoma. The most common attachment site of right heart myxoma is the atrial septum. The mean operative duration and cardiopulmonary bypass time of right heart myxoma resection were 207.71 ± 53.40 minutes and 63.86 ± 29.73 minutes, respectively, with an in-hospital mortality rate of 3.57%. During the follow-up, 2 patients died of noncardiac causes. The overall 1-, 2-, and 5-year actuarial survival rates after right heart myxoma resection were 95.8%, 90.8%, and 84.7%, respectively.

CONCLUSIONS

As a rare cardiac tumor, the clinical characteristics of right heart myxoma are different from typical left heart myxoma in some aspects, such as sex, asymptomatic rate, and embolization rate. Prompt surgical resection of right heart myxoma gives excellent early and midterm results.

Risk factors assessment and a Bayesian network model for predicting ischemic stroke in patients with cardiac myxoma

Objective

This study aims to identify relevant risk factors, assess the interactions between variables, and establish a predictive model for ischemic stroke (IS) in patients with cardiac myxoma (CM) using the Bayesian network (BN) approach.

Methods

Data of patients with CM were collected from three tertiary comprehensive hospitals in Beijing from January 2002 to January 2022. Age, sex, medical history, and information related to CM were extracted from the electronic medical record system. The BN model was constructed using the tabu search algorithm, and the conditional probability of each node was calculated using the maximum likelihood estimation method. The probability of each node of the network and the interrelationship between IS and its related factors were qualitatively and quantitatively analyzed. A receiver operating characteristic (ROC) curve was also plotted. Sensitivity, specificity, and area under the curve (AUC) values were calculated and compared between the BN and logistic regression models to evaluate the efficiency of the predictive model.

Results

A total of 416 patients with CM were enrolled in this study, including 61 with and 355 without IS. The BN model found that cardiac symptoms, systemic embolic symptoms, platelet counts, and tumor with high mobility were directly associated with the occurrence of IS in patients with CM. The BN model for predicting CM-IS achieved higher scores on AUC {0.706 [95% confidence interval (CI), 0.639-0.773]} vs. [0.697 (95% CI, 0.629-0.766)] and sensitivity (99.44% vs. 98.87%), but lower scores on accuracies (85.82% vs. 86.06%) and specificity (6.56% vs. 11.48%) than the logistic regression model.

Conclusion

Cardiac symptoms, systemic embolic symptoms, platelet counts, and tumor with high mobility are candidate predictors of IS in patients with CM. The BN model was superior or at least non-inferior to the traditional logistic regression model, and hence is potentially useful for early IS detection, diagnosis, and prevention in clinical practice.

A Rare Cause of Chest Pain Identified on Point-of-care Echocardiography: A Case Report

INTRODUCTION

Cardiac masses are a rare cause of chest pain. They can often be missed on a chest radiograph performed to evaluate non-specific chest pain and are not readily evaluated with traditional laboratory testing. However, these masses can be visualized with point-of-care ultrasound.

CASE REPORT

We present a case of a 19-year-old female presenting with intermittent chest pain, palpitations, and weakness present for two months. The patient had previously been evaluated at our emergency department one week earlier and was diagnosed with anxiety before being discharged. Besides a tachycardic and labile heart rate, physical examination and laboratory testing were unremarkable. Point-of-care cardiac echocardiography subsequently demonstrated findings concerning for a cardiac mass.

CONCLUSION

Cardiac masses are a rare cause of chest pain and palpitations that are easily missed. The advent of point-of-care ultrasonography has afforded us the ability to rapidly assess for structural and functional cardiac abnormalities at bedside, and incorporation of this tool into the evaluation of patients with chest pain offers the ability to detect these rare pathologies.

Benign Cardiac Neoplasms in the United States: A Thirteen-Year Review

Cardiac neoplasms are uncommon tumors. For epidemiological purposes, they can be divided into benign and malignant subtypes, with the former occurring at a significantly higher rate than the latter. Due to their uncommon nature, there are few data-driven studies examining the characteristics and trends of benign cardiac neoplasms. Our retrospective HCUP-NIS data review purports to illuminate some of the trends surrounding benign cardiac neoplasms and their associated co-occurrences. The data consisted of 482,872,274 weighted discharges. There were 45,568 weighted discharges that included a benign cardiac neoplasm. Benign cardiac neoplasms were more often observed in women (64.33%), and the average age was 63.8 years. The most common cardiovascular co-occurrences in patients with benign cardiac neoplasm were atrial tachyarrhythmias (28.93%), heart failure (19.61%), and embolic events such as stroke, myocardial infarct, or pulmonary embolism (19.82%). Other co-occurrences included pulmonary hypertension (7.55%), ventricular arrhythmias (3.23%), and other EKG abnormalities (3.70%). Procedures were numerous in patients with benign cardiac neoplasms. 43% of patients with this diagnosis had some form of cardiac surgery during their hospitalization. Overall, this study found low incidence of benign cardiac neoplasms in the USA during this 13-year study period. However, in the presence of benign cardiac neoplasms, our study showed that cardiovascular co-occurrences are not uncommon and may help to illuminate this otherwise rare diagnosis.

Risk factors of embolism for the cardiac myxoma patients: a systematic review and metanalysis

Background

The risk factors contributing to embolism in cardiac myxoma (CM) are yet controversial. This systematic review and meta-analysis aimed to clarify the risk factors of embolism for the CM patients.

Methods

PubMed, Embase, Cochrane library, Web of Science, China National Knowledge Infrastructure, Wan Fang, and Wei Pu databases were searched from inception to June 2019. Statistical analysis was conducted using Stata version 14.0. The pooled odds ratio or mean difference with 95% confidence interval was estimated for each risk factor.

Results

Herein, 12 studies, encompassing 1814 patients, were included. The pooled results suggested that New York Heart Association (NYHA) class I/II (P < 0.01), hypertension (P = 0.03), irregular tumor surface (P < 0.01), tumor in atypical location (P = 0.01), narrow base of tumor (P < 0.01), and increased fibrinogen (FIB) (P < 0.01) are significant risk factors of embolism in CM patients. However, sex, age, body mass index, smoking, left ventricular ejection fraction, diabetes, hyperlipidemia, atrial fibrillation, valvular heart disease, coronary heart disease, tumor size, platelet count, white blood cells, and hemoglobin were not associated with embolism (all P > 0.05).

Conclusions

NYHA class (I/II), hypertension, irregular tumor surface, atypical tumor location, the narrow base of tumor, and increased FIB were significant risk factors of embolism in CM patients. For CM patients with these factors, early surgery might be beneficial to prevent embolism.

A Case of Cerebral Tumor Embolism from Extracardiac Lung Cancer Treated by Mechanical Thrombectomy

Cerebral tumor embolism is a rare cause of acute ischemic stroke, and extracardiac carcinoma is an extremely rare cause. A 34-year-old man who had been diagnosed with lung cancer developed right hemiparesis and aphasia, with the National Institutes of Health Stroke Scale (NIHSS) score of 17. Magnetic resonance imaging (MRI) showed early ischemic change in the insular cortex and frontotemporal lobe and left internal carotid artery (ICA) terminal occlusion was confirmed by magnetic resonance angiogram (MRA). Mechanical thrombectomy (MT) with contact aspiration by a Penumbra ACE 68, followed by combined technique with a stent retriever was performed, and a soft, fragile embolus was retrieved. Finally, good recanalization was achieved (Thrombolysis in Cerebral Infarction [TICI] scale 2b), and on the next day, the right hemiparesis and aphasia were improved. However, the patient’s general condition gradually worsened, and 43 days after thrombectomy, he died from respiratory failure. The retrieved embolus was examined pathologically and diagnosed as mucoepidermoid carcinoma of the same type as his lung cancer. Chest computed tomography (CT) showed that tumor invaded the right pulmonary vein and left atrium; these findings suggested that a piece of the tumor in the left atrium flowed into the left ICA and caused the acute ischemic stroke.

Cardiac papillary fibroelastoma arising from the opening of the left inferior pulmonary vein in left atrium: A rare case report

RATIONALE

Cardiac papillary fibroelastoma is a small, benign endocardial tumor, while it is clinically important because of its strategic position and propensity for causing embolic events and hemodynamic complications.

PATIENT CONCERNS

A 59-year-old female presented our hospital for investigation and treatment of a sudden onset of syncope lasted about 2 minutes.

DIAGNOSES

Cardiac papillary fibroelastoma arising from left inferior pulmonary vein in left atrium.

INTERVENTIONS

The tumor was successfully removed by cardiac surgery.

OUTCOMES

The patient's postoperative course was uneventful, and she was discharged 10 days after surgery. The patient remained free of neurologic deficits and had no evidence of residual or recurrence of tumor with echocardiography during 1 year of follow-up.

LESSONS

Cardiac papillary fibroelastoma is a benign tumor, with increased risk of thromboembolic events. It is often diagnosed in patients with echocardiography by chance or after a neurologic event. Complete surgical resection should be considered when the patient is indicated and the long-term postoperative prognosis is excellent.

Long-term outcome of patients with atrial myxoma after surgical intervention: analysis of 403 cases

OBJECTIVE

To assess long-term survival and late cardiovascular events in patients with atrial myxoma after surgical intervention.

METHODS

Retrospective analysis of 403 patients undergoing resection of atrial myxoma from January 2002 to December 2016 was conducted with a median follow-up period of 4.5 (range: 0.5-15) years.

RESULTS

The cross-clamp time and cardiopulmonary bypass times were 41.1 ± 21.4 and 65.2 ± 27.3 min, respectively. A diagnosis of myxoma was histopathologically confirmed in all cases. The early in-hospital mortality rate was 0.7% (n = 3). During the follow-up period, tumor recurrence occurred in six patients and cerebral infarction in nine. There were 48 (11.9%) patients with late onset atrial fibrillation (AF). By multivariate analysis, age (HR = 1.05, 95% CI: 1.02-1.09, P < 0.001), left atrial diameter (HR = 1.23, 95% CI: 1.08-1.36, P = 0.012), and mitral valve surgery (HR = 1.17, 95% CI: 1.05-1.29, P = 0.027) were independent predictors of late onset AF. Twenty-one (5.2%) patients died during the follow-up period. Advanced age (HR = 1.07, 95% CI: 1.04-1.10, P = 0.003) and multiple surgical procedures (HR = 1.18, 95% CI: 1.06-1.29, P = 0.012) were significantly associated with overall mortality.

CONCLUSIONS

Atrial myxoma can be resected with good long-term survival. Late onset AF is common after surgery in patients with atrial myxoma. Advanced age, left atrial diameter, and mitral valve surgery were independent predictors of outcomes.

Acute Coronary Syndrome Management in Cancer Patients

PURPOSE OF REVIEW

Coronary artery disease and cancer often co-exist. Patients with cancer have been excluded by most major cardiology trials and registries and their management remains largely empiric. Cancer patients experience an approximately 10-times increased mortality compared to the general population. Conservative therapy of ACS in cancer therapy results in 1-year mortality of 74%. This review article aims to describe the mechanisms of acute coronary syndromes in cancer patients, their clinical presentation, and their management.

RECENT FINDINGS

Newer studies have shed light on the mechanisms of ACS in cancer patients, which are different and related to the type of malignancy and its associated therapy. Medication-specific coronary effects (vasospasm, endothelial dysfunction, spontaneous thrombosis, accelerated atherosclerosis), radiation vasculitis, cancer cell coronary embolism, and coronary compression from thoracic malignancies are unique ACS mechanisms in cancer patients. Close collaboration between oncologists and cardiologists for thoughtful patient selection and decision making strategies is necessary to provide optimal medical care.

Prevalence of primary cardiac tumor malignancies in retrospective studies over six decades: a systematic review and meta-analysis

The incidence of patients diagnosed with primary malignant cardiac tumors (PMCTs) has increased greatly in the past few decades. Whether this rising prevalence is due to overdiagnosis or an increased malignancy rate of primary cardiac tumors (PCTs) remains unclear. Therefore, we performed a systematic review and meta-analysis of published retrospective studies to determine whether the malignancy rate has been increasing over time. Published studies containing relevant data between 1956 and 2014 were evaluated. Two authors searched for all retrospective studies that included patients diagnosed with PCT and PMCT. Two other investigators independently extracted the data, and discrepancies were resolved by consensus. A random-effects meta-analysis model and cumulative meta-analysis model were used to evaluate the pooled prevalence and trend of dynamic change in PCT malignancies. The effects of time, study period and sample size were studied using a logit-linear regression model with robust error variance and a time variable. Thirty-eight studies involving 5,586 patients were analyzed. The pooled prevalence of PMCT among the patients diagnosed with PCT was 9.9% (95% CI, 8.4% to 11.4%) (I²=70%; P< 0.001), and this prevalence has been stable since around 2003. In the regression model, the malignancy odds ratio remained stable from 1975 onward, and no time effect was observed. Our study confirms that PMCT is uncommon, and the prevalence of PCT malignancies remained stable in the past few decades. The clinically observed increase in incidence is unlikely to reflect a true population-level increase in tumorigenesis. This result strongly suggests that the observed increase in incidence of PMCT most likely reflects increased diagnostic detection over time.

Metastatic leiomyosarcoma presenting as a lung mass with left atrial extension: case report and anesthetic management

Introduction

Lung metastasis of leiomyosarcoma that protrudes into the left atrium is an extremely rare condition. Severe complications may occur that prominently increase the mortality during the perioperative period. Currently, the anesthetic management reports are limited and there is no generally acknowledged algorithm available.

Case presentation

A 67-year-old man presented with cough and dyspnea for 10 days. Workup revealed bilateral pulmonary effusion. Transthoracic echocardiography showed a large mass in the left atrium. Urgent surgical resection under cardiopulmonary bypass was performed. We focused on oxygenation improvement and cardiac function management by applying protective ventilation with low positive end expiratory pressure, low dose inotropic agents, and other methods to maintain stable homeostasis. Results of biopsy established a diagnosis of metastatic leiomyosarcoma.

Conclusion

We reported a case of metastatic leiomyosarcoma presenting as a lung mass with left atrial extension and anesthetic management during surgical resection. Treating acute heart failure and refractory hypoxemia was the key focus perioperatively.

Infiltrating Lipoma of the Right Ventricle Involving the Interventricular Septum and Tricuspid Valve: Report of a Rare Case and Literature Review

Cardiac lipoma, which are primary cardiac tumors, are rare entities often detected incidentally during imaging. There have been very few reports on the right ventricle (RV) lipoma. Here, we present a case of RV infiltrating lipoma involving the interventricular septum (IVS) and the tricuspid valve. Clinical symptoms, diagnostic procedures, multimodality imaging characteristics, and treatment are discussed, and the complete clinical data of this case and relevant details of retrospective literature are reviewed. The study described the case of a 48-year-old woman who suffered from occasional palpitation after exertion for 10 years. Imaging examinations, including echocardiography and cardiovascular magnetic resonance imaging (MRI), revealed a large mass adherent to the IVS and the right ventricular wall that was consistent with lipoma. The patient underwent surgical repair of the tricuspid valve and excision of the partial mass. The gross specimen revealed piles of 5 × 4 × 3 cm fragments with yellowish appearance and pathological results showed infiltrating lipoma.Lipoma is often asymptomatic and diagnosed incidentally. Surgical excision is the main therapeutic intervention, which is always performed in cases of symptomatic lipoma or when malignancy is suspected. Multimodality imaging would be great help in the diagnosis of cardiac lipoma. Echocardiography is a convenient method for follow-up.

Fibroelastoma Recurrence in Left Ventricle: Rarity of Primary Cardiac Tumor

Cardiac papillary fibroelastoma (CPF) is a primary cardiac neoplasm usually detected by echocardiography. Left ventricular fibroelastomas are extremely rare. The incidence of CPF is between 0.0017 and 0.33% during autopsy studies. We report a 70-year-old man who had papillary fibroelastoma discovered and resected in 2005 that recurred in 2013. The tumor grew rapidly from 2013 to 2014. A bioprosthetic mitral valve was placed in 2014. Due to the location and nature of the recurrent tumor, mitral valve replacement was the treatment of choice to prevent a third recurrence of the fibroelastoma. The patient was discharged from the hospital on postoperative day 9.

Risk factors for embolism in cardiac myxoma: a retrospective analysis

BACKGROUND

Myxomas are the most common primary heart tumors and are closely associated with embolic events. Cardiac myxomas typically arise from the interatrial septum at the border of the fossa ovalis in the left atrium. Any other location is considered atypical. Embolism, one of the complications of myxoma, is associated with high morbidity and mortality. The aim of this study was to investigate the risk factors for embolism in patients with cardiac myxoma.

MATERIAL AND METHODS

In this retrospective study, a cohort of 162 patients with cardiac myxomas was surgically treated between January 1998 and June 2014 at 3 cardiac centers in China. Preoperative data, including platelet count, sex, age, and the tumor (size, location, surface, and attachment), were compared between embolic and non-embolic groups of patients.

RESULTS

No significant differences in vascular risk factors were seen between the 2 groups. However, the percentage of higher platelet count (>300 × 10(9)/L) and mean platelet volume in the embolic group were significantly higher than in the non-embolic group (P=0.0356, and 0.0113, respectively). Irregular surface and atypical location of the myxomas were also independently associated with increased risk of embolic complications.

CONCLUSIONS

Tumor location, macroscopic appearance, mean platelet volume, and high platelet count are strong risk factors for embolic events in patients with cardiac myxomas.