Surgical Treatment for Pulmonary Embolization of a Right Atrial Myxoma Vera N. Merli, MD, Sonia Dell’Oglio, MD, Valentina Grazioli, MD, Cristian Monterosso, MD, Benedetta Vanini, PhD, Mauro Gori, MD, Giovanni Quarta, MD, and Andrea M. D’Armini, MD Department of Cardiothoracic and Vascular Surgery, Foundation “I.R.C.C.S. Policlinico San Matteo,” University of Pavia, School of Medicine, Pavia; and Cardiovascular Department, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy We report the case of a woman with pulmonary embolism due to a cardiac mass. Echocardiography, computed to- mography scan, and cardiac magnetic resonance raised the suspicion of right atrial myxoma and confirmed the pres- ence of pulmonary embolism. The patient was sent to the University of Pavia School of Medicine, where the atrial myxoma was excised, and, using interrupted periods of circulatory arrest, extraction of the myxoma emboli from the pulmonary arteries was performed. No adjuvant chemotherapy was required as surgical treatment is an effective therapy in cases of pulmonary embolism of a benign neoplastic mass. (Ann Thorac Surg 2019;107:e245–6) Ó 2019 by The Society of Thoracic Surgeons M yxoma is the most common benign cardiac tumor. It usually affects the left atrium but, rarely, arises from the right atrium and pulmonary embolism may occur as a complication [1]. The presence of a mass affecting the right atrium and pulmonary arteries can suggest the neoplastic nature of the lesions. In this case, surgical removal of both atrial mass and pul- monary emboli has to be considered as curative treatment. A 33-year-old woman with past medical history of auto- immune hypothyroidism and breast fibroadenomas was admitted to the emergency department of Papa Giovanni XXIII Hospital (Bergamo, Italy) with dyspnea, tachy- cardia, and fever. Electrocardiogram showed sinus tachycardia and the McGinn-White sign (S1Q3T3). D- Dimer was markedly elevated (6,583 ng/L). Transthoracic and transesophageal echocardiography showed a large, mobile mass in the right atrium (4.5 cm 2.4 cm), partially attached to the interatrial septum and atrial free wall, with a portion bulging into the inferior vena cava and another part floating towards the tricuspid valve. The right ventricle was dilated with mild dysfunction. A chest computed tomography (CT) scan documented bilateral massive pulmonary embolism and confirmed the pres- ence and extension of the mass. Unfractioned heparin was started. A few days later, the patient underwent cardiac magnetic resonance imaging, which further delineated the anatomy of the mass and supported the suspicion of its myxomatous nature (Fig 1). In addition, it showed the same large filling defects in pulmonary ar- teries, despite several days of full range anticoagulant therapy. The patient was then transferred to San Matteo Hospital in Pavia for the surgical removal of the mass. The surgical approach was obtained via medial ster- notomy and cardiopulmonary bypass with aortic and cava-femoral vein cannulation. Myocardial protection was achieved through moderate hypothermia (24 C), left ventricular venting, and electrically induced ven- tricular fibrillation, without aortic clamping. The right atrium was incised parallel to the interatrial groove. A gelatinous floating mass (4.0 cm 5.0 cm) appeared with interatrial septum implantation near the inferior vena cava orifice, coronary sinus, and fossa ovalis. The pedicle of the right atrial mass was completely excised and interatrial septum was rein- forced by surgical stitches without patch or reconstruc- tion procedures. Successively, atriotomy was sutured. Considering CT scan findings, the main pulmonary ar- tery was longitudinally incised to remove embolic ma- terial from pulmonary arterial branches, in the same way as in pulmonary endarterectomy but without identifying a dissection plane. Repeated short periods (7 to 10 minutes) of circulatory arrest followed by reper- fusion intervals (at least 5 minutes) were adopted, as in pulmonary endarterectomy. Cerebral perfusion was monitored by near-infrared spectroscopy. Total cardio- pulmonary bypass time was 245 minutes (Fig 2). Immediate postoperative period was uneventful. The patient was extubated on the first postoperative day and discharged from the intensive care unit on the third postoperative day. The histopathology revealed the mass to be an atrial myxoma. After 4 months of follow-up the patient is doing well. Right ventricular function is normal and CT scan is negative for neoplastic lesions in cardiovascular struc- tures. The patient signed consent for publication of her anonymous clinical data. Comment Right atrial myxoma is a rare benign cardiac neoplastic mass, with an incidence of 0.0017% in the general population [2]. It arises sporadically in the majority of cases and it is more common in middle-aged women. A familial pattern with autosomal dominance inheri- tance, in contrast, is seen in approximately 7% of cases, with a similar prevalence in male and female patients Accepted for publication July 26, 2018. Address correspondence to Dr Merli, Cardiac Surgery, Foundation “I.R.C.C.S. Policlinico San Matteo”, Viale Golgi 19, 27100, Pavia, Italy; email: [email protected]. Dr D’Armini discloses a financial relationship with Actelion Pharmaceuticals Ltd, Bayer HealthCare, and Merk Sharp Dohme. Ó 2019 by The Society of Thoracic Surgeons 0003-4975/$36.00 Published by Elsevier Inc. https://doi.org/10.1016/j.athoracsur.2018.07.095
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