IgG4-related Disease Involving the Cardiovascular System: An Intracardiac Mass and a Mass Lesion Surrounding a Coronary Artery

A 61-year-old Japanese man with IgG4-related autoimmune pancreatitis developed a mass in the right atrium (RA) and a mass lesion surrounding the left anterior descending coronary artery. We performed an intracardiac echo catheter-guided percutaneous biopsy of the RA mass, and histologically diagnosed it as IgG4-related disease. Oral corticosteroid therapy gradually downsized the mass lesions. We encountered a very rare case with mass lesions in the cardiovascular system of the IgG4-related disease that were able to be diagnosed using an intracardiac echo-guided biopsy.

Image of the month: Ventricular myxoma mimicking hypertrophic cardiomyopathy

A 5-year-old boy with an incidentally detected cardiac murmur was referred for evaluation. Tall R waves were noted in the electrocardiogram in leads V3 and V4. Transthoracic echocardiography suggested asymmetric septal hypertrophy with diffuse thickening of the inter-ventricular septum with normal thickness of the posterior left ventricular wall. Upon closer interrogation, a masquerading sessile cardiac mass was identified adherent to the left ventricular side of the inter-ventricular septum which appeared to contract with each cardiac cycle, mimicking hypertrophic cardiomyopathy.

"A ball in a cage"

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[A Case of Myocardial and Cutaneous Metastases of Squamous Cell Lung Cancer Post Left Pneumonectomy and Radical Surgery for Cutaneous Metastasis during Nivolumab Therapy]

BACKGROUND

Concomitant myocardial and cutaneous metastases of squamous cell lung cancer after left pneumonectomy are very rare. Although nivolumab is used as a standard second-line chemotherapy for non-small cell lung cancer(NSCLC), its efficacy for concomitant myocardial and cutaneous metastases remains unclear.

CASE

A 66-year-old man with no chief complaints was diagnosed with myocardial metastasis by CT scan. The patient underwent radical left pneumonectomy for squamous cell lung cancer 12 months previously and had rejected adjuvant chemotherapy with pT2aN1M0- II B(7th edition). A skin lesion in the left side of the neck was diagnosed as cutaneous metastasis by cytological examination. First-line treatment with cisplatin plus gemcitabine was administered; it was then replaced with nivolumab as a second-line chemotherapy after the progression of the disease due to myocardial metastasis. Fortunately, after 5 courses of nivolumab, there was a reduction in the cutaneous metastasis, which allowed complete resection, and reduction in the volume of myocardial metastasis. The patient is alive 30 months after left pneumonectomy and 18 months after the diagnosis of relapse. Nivolumab treatment is on-going.

CONCLUSION

Complete resection of a cutaneous metastasis of squamous cell lung cancer and a reduction in the volume of myocardial metastasis were achieved following nivolumab treatment. Thus, nivolumab is a useful chemotherapy for concomitant cutaneous and myocardial metastases of squamous cell lung cancer.

Hemodynamic management of a patient with a huge right atrium myxoma during thoracic vertebral surgery: A case report

RATIONALE

Myxoma is the most common primary benign cardiac tumor, which could lead to some fatal complications because of its strategic position.

PATIENT CONCERNS

The patient was admitted to our hospital due to sudden onset of palpitation, chest tightness, mild fever, night sweats, accompanied with bilateral lower extremities adynamia, and paralysis for 5 days, but no obvious syncope and edema.

DIAGNOSES

Transthoracic echocardiography showed a giant mobile myxoma (72 × 58 mm) in the right atrium (RA). Magnetic resonance imaging revealed an erosive space-occupying lesion located between the first and third thoracic vertebrae.

INTERVENTIONS

Thoracic vertebral lesions were resected immediately to rescue the incomplete paraplegia. After the patient was placed in the prone position, significant hemodynamics changes were observed due to the displacement of the huge RA myxoma.

OUTCOMES

Stable hemodynamics was maintained during the operation through control of fluid infusion combined with vasoactive drugs.

LESSONS

Change in body position may lead to obstruction of intracardiac blood flow in patients with giant myxoma. This clinical manifestation is rarely reported.

One-stage surgery for removal of intravascular leiomyomatosis extending to right ventricle

RATIONALE

Intravascular leiomyomatosis (IVL) is a rare nonmalignant tumor that can be fatal if untreated.

PATIENT CONCERNS

A 49-year-old nulliparous Asian woman who underwent hysterectomy and left salpingo-oophorectomy for multiple uterine leiomyomas 18 months prior presented complaining of intermittent palpitation and chest tightness for approximately 1 month. Echocardiography revealed a large mobile tumor mass extending from the inferior vena cava (IVC) to the right atrium that partially obstructed IVC flow and tricuspid inflow. Thoracicabdominopelvic computed tomography revealed a left adnexal tumor (4.8 × 2.5 cm) causing intravascular obstruction extending from the left internal iliac vein to the IVC, right atrium, and right ventricle.

DIAGNOSIS

IVL with right heart involvement INTERVENTIONS:: Under cardiopulmonary bypass, a one-stage surgery combining sternotomy and laparotomy was performed. The tumor was approached and extracted via sternotomy, and tumor detachment and removal of residual tumors was accomplished via laparotomy.

OUTCOMES

A firm, smooth, and regularly shape tumor 15.5 × 5.5 × 2.5 in size was completely removed and histopathologically confirmed as IVL. The patient tolerated the surgical procedure well and no postoperative complication was noted.

LESSONS

We describe a one-stage surgical approach to completely remove an IVL extending to the right ventricle.

Metastatic cardiac tumor presenting as atrial fibrillation in a previously healthy woman: A case report

RATIONALE

Metastatic cardiac tumor (MCT) is rare in clinical practice. MCT presenting initially as atrial fibrillation (AF) is even rarer.

PATIENT CONCERNS

We report a 47-year-old woman with no previous medical history presented with intermittent palpitation for 3 days.

DIAGNOSES

The electrocardiography showed AF with rapid ventricular rate. The transthoracic echocardiography showed a 4 × 4 cm mass occupying the left atrium (LA). The contrast enhanced computed tomography (CT) showed a left lower lung mass with invasion to the LA and left upper pulmonary vein (PV). The chest CT guided biopsy revealed poorly differentiated squamous cell carcinoma. Further workup including bone scan showed no significant findings. The diagnosis of lung squamous cell carcinoma with cardiac invasion was made.

INTERVENTIONS

She went on to received palliative chemotherapy.

OUTCOMES

She is being followed up regularly at the outpatient department.

LESSONS

Tumor invasion of the LA and PV was thought to be the cause of the AF. This condition is rare, but clinically important. Physicians should be alert that MCT could be an important differential diagnosis in patients presenting with unexplained AF.

[Haemangioma of the left atrium]

Presented herein is a clinical case report concerning successful surgical management of a rare variety of a primary tumour of the heart, i. e., a capillary haemangioma of the left atrium, simulating by the contours and localization a myxoma. The final diagnosis was verified only by histological examination. The authors describe difficulties of diagnosis of the disease involved, underlying the necessity of plastic correction for restoration of the normal anatomical configuration of the heart. This is followed by a review of the literature, reflecting a possible course of the disease, problems of diagnosis, and therapeutic policy.

[LISHUTA EXTRANODAL INVOLVEMENT OF THE HEART IN LYMPHOMAS: A CLINICAL CASE OF LARGE B-CELL LYMPHOMA AND LITERATURE REVIEW]

The authors report a case of rare cardiac involvement in lymphoma, one of the manifestations of which was rhythm and conduction disorders with their resolution after chemotherapy. Also presented are clinical manifestations of heart lesions in lymphoma and modern methods of their diagnostics and treatment.

[Left atrial giant myxoma incidentally discovered during endoscopic ultrasonography; report of a case]

A 49-year-old female patient with a symptom of dysphagia underwent endoscopic ultrasonography (EUS) of the upper gastrointestinal tract, which incidentally revealed a tumor compressing the esophagus from outside. Transthoracic echocardiography performed after EUS showed a giant tumor in the left atrium. The tumor, measuring 75×68×43 mm, weighing 105 g was successfully removed, and pathologically diagnosed as myxoma. Her symptom disappeared completely. When performing clinical studies, it is important to pay every attention not to miss any abnormal findings beyond the scope of targeted areas. We also mentioned an ambiguity of the term," giant" regarding the size and weight of myxoma.

[Successful excision of a left ventricular fibroma in an adult patient; report of a case]

A 55-year-old man was referred with a diagnosis of a left ventricular thrombus. Echocardiography revealed that he had a thrombus in the free wall of the left ventricle. Under cardiopulmonary bypass, we removed the intramural tumor. After the removal, the defect was repaired by Dor operation. Pathological examination revealed the tumor was a cardiac fibroma. He is doing well without any troubles 3 years after the operation.

Cardiac myxoma originating from areas of ventricular akinesia

We present a case of large pedunculated myxoma (61×39 mm) in the left ventricular cavity with anterior-septal and anterior free wall akinesia. Angiographic study showed normal coronary arteries, but the clinical signs strongly suggested a previous myocardial infarction. We cannot exclude the possibility that the ventricular akinesia results from embolization of tumor fragments. For a time, cardiac myxomas were believed to arise from mural thrombi. In this case the presence of blood stasis or low-velocity blood flow related to wall motion abnormalities may have played a role in improving tumor growth.

Multiple papillary fibroelastoma: report of a case and implications for management

A 59-year-old woman with chest discomfort was transferred to our hospital. Echocardiography was suggestive of multiple papillary fibroelastoma (PFE). Tumors on both the left and right coronary cusps were confirmed macroscopically and pathologically and a small tumor was noted microscopically on the non-coronary cusp. Aortic valve replacement was successfully performed. The treatment and recurrence rate of PFE is controversial due to its rarity. Given that multiple tumors were seen in the present case and that possible recurrence has been reported elsewhere, valve replacement may be a better choice for surgical repair than valvoplasty in some cases, such as a single PFE in which plasty may be difficult or multiple PFEs regardless of impaired valve function.

Cardiac tumours in infancy

Cardiac tumours in infancy are rare and are mostly benign with rhabdomyomas, fibromas and teratomas accounting for the majority. The presentation depends on size and location of the mass as they tend to cause cavity obstruction or arrhythmias. Most rhabdomyomas tend to regress spontaneously but fibromas and teratomas generally require surgical intervention for severe haemodynamic or arrhythmic complications. Other relatively rare cardiac tumours too are discussed along with an Indian perspective.

Asymptomatic pediatric pulmonic valve myxoma involving the right ventricular outflow tract: a case report and review of the literature

Asymptomatic pediatric pulmonic valve myxoma involving the right ventricular out flow tract (RVOT) is very rare. The case is presented of 13-year-old asymptomatic boy who was referred to the cardiology clinic for evaluation of murmur, and was found to have a large mobile mass (3 x 2 cm) in the RVOT that protruded into the pulmonary artery across the pulmonary valve during systole, and relocated in the right ventricle in diastole. The patient underwent successful surgical excision of the tumor, which had a short stalk attached to the pulmonary valve. Macroscopic examination revealed a typical myxoma without any evidence of malignancy. This case elaborates the importance of early recognition and surgical excision of these tumors in order to prevent thromboembolic complications.

[Cardiac angiosarcoma in a pregnant women]

We present a case of cardiac angiosarcoma in a pregnant women. Clinical manifestations of angiosarcoma were unspecific and progressed rapidly as hemopericardium, cardiac tamponade, heart failure, fever, chest pain. Pregnancy was interrupted at 22-nd week. The patient died in 6 months after appearance of first symptoms.

Large atrial myxoma causing mitral obstruction and severe pulmonary hypertension

Myxoma is the most common type of cardiac tumor, accounting for 30-50% of all primary cardiac tumors. Clinically, patients usually present with at least one of the classic triad of obstructive cardiac, embolic, and constitutional signs. The case is reported of a large atrial myxoma in the left atrium which caused mitral valve obstruction, leading to severe pulmonary hypertension and right heart failure, mimicking rheumatic mitral stenosis. Postoperatively, a fall occurred in the patient's pulmonary artery pressure and she showed clinical improvement.

A case report of right ventricular mass

Primary Cardiac tumors are uncommon during infancy and childhood. Myxomas originating in the right ventricles are even less common in paediatric patient. Our patient baby Rani, 3 months of age presented with shortness of breath and chest indrawing. Antenatal history and delivery was uneventful. The baby was under weight and also malnourished but there was no cyanosis and clubbing. Her respiratory rate was 25/minute. On precordium examination, first heart sound (S1) was normal but pulmonary component of second heart sound (P2) was soft. There was an ejection systolic murmur (Grade-3/6) in the left upper para-sternal area. Chest X-ray revealed cardiomegaly. Echocardiogram revealed a large mass (11x10mm) in the right ventricle, dynamically obstructing the right ventricular out-flow tract and compressing the left ventricle. There was a Tricuspid regurgitation (Grade-2) and moderate pulmonary hypertension (PASP-50 mmHg).

Implantable cardioverter defibrillator as a bridge to recovery in an infant with cardiac rhabdomyoma

Multiple cardiac rhabdomyomas in an infant presented with recurrent life-threatening ventricular arrhythmias refractory to medical treatment and necessitating the placement of an implantable cardioverter defibrillator (ICD). The device functioned effectively as a bridge to recovery during a 2-year follow-up period, when the tumor showed spontaneous regression, along with an almost complete resolution of the ventricular arrhythmias. We conclude that childhood cardiac rhabdomyomas causing severe drug-refractory ventricular arrhythmias can be managed by ICD therapy.

Hemangioma located just above the left main coronary artery, in a subject who had cardiac arrest due to ventricular fibrillation, led to a diagnosis of Brugada syndrome

We report the case of a 38-year-old Asian man with a pericardial hemangioma on the left main coronary artery. The patient presented initially at our hospital after cardiopulmonary resuscitation following an episode of ventricular fibrillation (VF). Because of spontaneous coved-type ST segment elevation on the higher intercostal space V1 to V2 in a 12-lead electrocardiogram, documented VF in the absence of structural heart disease, and a family history of sudden death, he was diagnosed with Brugada syndrome. Transesophageal echocardiography showed a smooth-surfaced mass with well-demarcated borders, directly above the left main coronary artery. Computed tomography confirmed the presence of the mass, which showed no enhancement at early phase, but did demonstrate homogenous enhancement at delay phase by contrast material. There were no findings from either the nuclear medicine or the tumor marker investigations which indicated that the mass located just above the main coronary arteries was malignant. Therefore, taken together, these findings suggested that the tumor might be a pericardial hemangioma. The relationship between the location of the hemangioma just above the left main coronary artery and the occurrence of VF was not clear, i.e. whether the presence of the hemangioma caused the stimulation of the left main coronary artery and as a result, led to the spasm of the left main coronary artery and the occurrence of VF. Furthermore, as the tumor did not extend into any of the adjacent structures, such as the coronary arteries or the right ventricular outflow tract, surgical resection was not performed; instead, the patient received a dual chamber implantable cardioverter-defibrillator.

An unusual cause of stroke from a left atrial mass

A 59-year-old woman was admitted to the hospital after having severe headache for 1 day. Her medical history was significant for coronary artery disease, diabetes, atrial fibrillation, and rheumatic heart disease. The patient was in remission from stage II left breast cancer (T2 N0 M0) in 1997, treated with lumpectomy, 6 cycles of chemotherapy (cyclophosphamide, methotrexate, and 5-fluorouracil), and local radiation therapy (total 6000 cGy). Head magnetic resonance imaging scan showed left occipital hemorrhage. Subsequent angiogram showed a possible mycotic aneurysm of distal parietal occipital branch of the posterior cerebral artery. Cardiology was consulted to evaluate for a cardioembolic source.

Pulmonary venous drainage through a highly vascularized left atrial tumor

We present a patient with symptomatic congestive heart failure due to a left atrial sarcoma infiltrating and apparently occluding the left pulmonary veins. The tumor was highly vascularized and enabled attenuated blood drainage from the left upper and lower pulmonary veins despite intra-operative appearance as completely obliterative, thus avoiding persistent left lung pulmonary edema. The tumor was partially removed and the pathologic findings showed advanced angiogenesis. Malignant tumors may occlude large blood vessels and thus may result in the development of a collateral flow. However, we suggest that highly vascularized tumors (macroscopic totally occlusive) may serve as a sponge and enable attenuated blood flow through the tumor and hence may avoid a complete cut off in blood supply or drainage.