Download Blood cyst of tricuspid valve: an incidental finding in a patient with

European Journal of Echocardiography (2009) 10, 588–589
doi:10.1093/ejechocard/jep029
Blood cyst of tricuspid valve: an incidental finding
in a patient with ventricular septal defect
Mustafa T. Agac*, Zeydin Acar, Turhan Turan, Bilgehan Karadag, Selim Kul, and Hakan Erkan
Department of Cardiology, Trabzon Numune Training and Research Hospital, Maras Street, Trabzon 61040, Turkey
Received 5 January 2009; accepted after revision 7 March 2009; online publish-ahead-of-print 2 April 2009
KEYWORDS
Blood cyst;
Tricuspid valve;
Ventricular septal defect;
Contrast echocardiography
Blood-filled cysts of heart valves are rare in adults. These cysts are diverticuli lined by endothelium and
filled with blood. They appear to be benign lesions and should be removed if they cause problems. We
present the case of a mobile tricuspid valve blood cyst that was incidentally found in a patient evaluated
for systolic heart murmur. Systolic murmur was found to originate from a muscular-type ventricular
septal defect of no haemodynamic significance. The lack of echocardiographic evidence of tricuspid
valvular dysfunction and indication for repair of co-existent ventricular septal defect suggested a
benign course and, therefore, we monitored the patient safely by echocardiography.
A 72-year-old woman presented with mild exertional dyspnoea of 3 years duration. She was normotensive and had
no history of myocardial infarction or angina. Physical examination revealed no abnormal finding except a high-pitched
systolic murmur best heard on lower left sternal border. Laboratory examination disclosed no abnormal finding of special
note. The electrocardiogram was normal except incomplete
right bundle branch block and chest roentgenogram did not
demonstrate any sign of abnormality. An echocardiogram
was ordered for further evaluation of abnormal heart
sound and left ventricular function. Echocardiography
demonstrated a small muscular-type ventricular septal
defect (Supplementary data online, Video S1) of no haemodynamic significance (QP/QS ¼ 1.2) and a mobile 2 cm 1.5 cm cystic mass attached to atrial side of septal tricuspid
leaflet (Figure 1A) which was prolapsing into right atrium
during systole and the right ventricle during diastole (Supplementary data online, Video S2). Doppler echocardiography showed mild tricuspid regurgitation without right
ventricular inflow obstruction due to cystic mass. Left ventricular systolic and diastolic functions were found to be
normal. The mass was well circumscribed, had a thin wall,
and echolucent core. For better characterization of the
mass, contrast echocardiography was performed with agitated saline and showed a closed cyst with no bubbles
entering into echolucent central core (Figure 1B and Supplementary data online, Video S3). Based on these
* Corresponding author. Tel: þ90 533 6544688; fax: þ90 462 2302307.
E-mail address: [email protected]
characteristic findings, we made a diagnosis of blood-filled
cyst of tricuspid valve, which is a rare condition in adults.
Discussion
Blood cyst of heart was first described in 1844 by Elsasser.1
They are usually congenital in origin, seen predominantly
in infants, and located on the endocardium, particularly
along the lines of closure of heart valves. During infancy,
these cysts may disappear spontaneously, and therefore
are rarely seen in older children and adults. The cysts are
most commonly present on the atrioventricular valves,
accounting for 96% of the cysts in infants, and are less
often present on pulmonary and aortic valves.2 Cyst wall
consists of endothelial cells and a thin layer of fibrous
tissue that consists non-organized blood or seroanguinous
fluid.3 Several theories have been entertained as a possible
pathogenesis of blood cysts. Invagination at crevices of the
valve surface into stroma by high ventricular pressure may
result in blood-filled cyst formation. Subsequently, the
mouths of the crevices may fuse to form a closed cyst.2 In
support of a closed cyst in the present case, we could not
see microbubbles entering inside the cyst during systole.
The differential diagnosis of right-sided cystic mass includes
aneurysmatic atrioventricular septum, cavitating thrombus,
right atrial myxoma, abscess formation as a sequel of endocarditis, hydatid cyst, and blood cyst. However, absence of
intracystic calcification, homogenous pattern of cystic
fluid, relation to the tricuspid valve, and clinical history
strongly suggested a blood cyst in our patient.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009.
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Blood cyst of tricuspid valve
589
have recommended surgical excision of these cysts in
asymptomatic patients.5 Others suggest that asymptomatic
cysts can be safely monitored by echocardiography, until
there is a clinical indication for removal. Michelena et al. 6
suggested that right-sided blood cysts may cause progressive
tricuspid valve dysfunction over several years probably by
exerting excess weight on the valve during systole that
causes worsening prolapse and chordal rupture. Although
the prior duration of blood cyst is unknown, this was not
the case for our patient in whom valvular functions were
found to be preserved. The lack of echocardiographic evidence of tricuspid valvular dysfunction and indication for
repair of co-existent ventricular septal defect suggested a
benign course for our patient, and therefore we planned
to monitor the patient until there is a clear indication for
surgery. Repeat echocardiography at 6 month and a year
after demonstrated preserved tricuspid valvular function
and no increase in cyst size.
In summary, we reported a case of a mobile blood cyst
of tricuspid valve incidentally found in a patient with a
small muscular septal defect. To our knowledge, this is the
first case reported in the literature where blood cyst
co-existed in an adult patient with ventricular septal
defect. We believe that blood cysts can successfully be
managed conservatively unless signs of valvular dysfunction
ensue.
Supplementary data
Supplementary data are available at European Journal of
Echocardiography online.
References
Figure 1 (A) Transthoracic echocardiographic modified apical four
chamber view of right ventricle (RV), right atrium (RA) and left atrium
(LA) showing cystic mass attached to septal tricuspid leaflet. Note the
thin wall of cyst and homogenous appearance of intracystic fluid. (B)
Transthoracic echocardiographic modified right ventricle inflow view
with agitated saline showing partial prolapse of cyst into right ventricle
during diastole. Note the absence of microbubbles in cystic cavity. RV
indicates right ventricle, RA right atrium, LV left ventricle.
Symptomatic blood cysts causing valvular dysfunction
should be excized.4 There is no consensus regarding the
optimal management of asymptomatic cysts. Some authors
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valve in an adult: report of a case and review of the literature. Hum
Pathol 1997;28:252–5.
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Blood-filled cysts of heart. Indian Heart J 2004;56:174–5.
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cyst: a rare finding. Ann Thorac Surg 1996;62:880–3.
6. Michelena HI, Mulvagh SL, Schaff HV, Enriquez-Sarano ML, Klarich KW. A
heart-shaped mass inside a heart: echocardiographic diagnosis, pathology,
and surgical repair of a flail tricuspid valve caused by a large blood-filled
cyst. J Am Soc Echocardiogr 2007;20:771.e3–6.