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Ann Thorac Surg
2005;79:1765–7
CASE REPORT
TURKOZ ET AL
HEMANGIOMA OF THE HEART
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5. Traversat J, Laine JF, Slama M, et al. Cardiac contusion with
dissecting hematoma of the apex of the heart and interventricular communication [in French]. Arch Mal Coeur Vaiss
1986;79:1105–9.
6. Pliam MB, Sternlieb JJ. Intramyocardial dissecting hematoma:
an unusual form of subacute cardiac rupture. J Card Surg
1993;8:628 –37.
Surgical Treatment of a Huge
Cavernous Hemangioma
Surrounding the Right Coronary
Artery
ventricular outflow obstruction leading to death. Di Bella
and co-workers [3] reported two cases of postinfarction
dissecting hematoma of the interventricular septum. Tejada
Artigas [4], Traversat [5], and their colleagues described two
cases of posttraumatic hematoma of the interventricular
septum. Pliam and Sternlieb [6] reviewed the history of
intramyocardial dissecting hematoma after myocardial infarction. They found 14 cases in the literature. Ninety
percent of patients treated with a conservative approach
died, whereas all patients treated surgically survived. Various complications after VSD closure have been reported
[1], but we are not aware of previous descriptions of an
intraseptal hematoma in this context.
In our patient, the signs of myocardial infarction followed by the rapid postoperative increase in the thickness of the interventricular septum suggest that bleeding
from a septal branch of the anterior descending coronary
artery may have occurred. However, we have no direct
confirmation of this supposition. The indication for
prompt drainage of the hematoma was the rapid worsening of clinical conditions and hemodynamic variables.
The draining of the hematoma, although partial, improved the patient’s clinical recovery. In conclusion,
intraseptal hematoma is a complication that can develop
after surgical VSD closure.
References
1. Ventricular septal defect. In: Castaneda AR, Jonas RA, Mayer
JE, Mayer JE Jr. Cardiac surgery of the neonate and infant.
Philadelphia: WB Saunders, 1994:187–202.
2. Ettles DF, Firth N, Nair RU, Williams GJ. Fatal acute left
ventricular outflow obstruction due to interventricular septal
haematoma— diagnosis by transesophageal echocardiography. Eur Heart J 1989;10:479 –81.
3. Di Bella I, Minzioni G, Maselli D, Pasquino S, Viganò M.
Septal dissection and rupture evolved as an inferobasal
pseudoaneurysm. Ann Thorac Surg 2001;71:1358 –60.
4. Tejada Artigas A, Laperal Mur JR, Caivo Cebollero I, Fernandez Gonzalez B, Gonzalez Manzanares JL, Placer Peralta L.
Contusion and post-traumatic hematoma of the interventricular septum. Report of a case [in Spanish]. Rev Esp Cardiol
1992;45:663–4.
© 2005 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Riza Turkoz, MD, Oner Gulcan, MD,
Levent Oguzkurt, MD, Hakan Atalay, MD,
Bulent Bolat, MD, and Alpay Sezgin, MD
Departments of Cardiovascular Surgery, Radiology, and
Cardiology, Baskent University, Adana, Turkey
Hemangioma of the heart is an extremely rare benign
cardiac tumor. A 61-year-old woman presented with a
huge hemangioma on the right ventricle. The tumor was
completely surrounding the right coronary artery. Under
cardiopulmonary bypass, the right coronary artery was
transected from the aortic sinus and the supplying arteries of the tumor were divided. The tumor was successfully resected, and the right coronary artery was reanastomosed to the aortic sinus.
(Ann Thorac Surg 2005;79:1765–7)
© 2005 by The Society of Thoracic Surgeons
T
hree-quarters of primary cardiac tumors are benign,
most of them are myxomas. Nonmyxomatous benign cardiac tumors are rare and most commonly consist
of lipoma, papillary fibroelastoma, and rhabdomyoma.
Hemangiomas of the heart are extremely rare with an
incidence of 1% to 2% of benign cardiac tumors. Cardiac
hemangioma may occur anywhere in the heart, but it is
usually found on the lateral wall of the left ventricle and
on the anterior wall of the right ventricle. Diagnosis of a
cardiac hemangioma is always difficult. The characteristic
sign on coronary angiography is a tumor blush and the
maps of blood supply to the tumor. A review of the cases
reported in the literature reveals that preoperative diagnosis of cardiac hemangiomas has been achieved in only
34% of these patients [1]. We report a case of huge
hemangioma located on the right ventricle surrounding
the right coronary artery (RCA), which was completely
removed with the aid of cardiopulmonary bypass.
A 61-year-old woman was admitted to our hospital with
palpitation and tightness of the chest. No abnormalities
were detected on physical examination. Her heart was in
Accepted for publication Oct 28, 2003.
Address reprint requests to Dr Turkoz, Baskent Universitesi Tip Fakültesi, Adana Uygulama ve Arastirma Hastanesi, Dadaloglu mah 39 sok No.
6, Adana 01250, Turkey; e-mail: [email protected].
0003-4975/05/$30.00
doi:10.1016/j.athoracsur.2003.10.100
FEATURE ARTICLES
Fig 2. Two-dimensional echocardiographic long-axis view of the left
ventricle showing an almost normal septal thickness 20 days after operation. The hematoma had been replaced by hyperechoic material.
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CASE REPORT
TURKOZ ET AL
HEMANGIOMA OF THE HEART
FEATURE ARTICLES
sinus rhythm (rate, 84 beats/min), and her blood pressure
was 110/70 mm Hg. An electrocardiogram showed a normal
sinus rhythm and nonspecific T-wave inversion in leads V1
through V6. The cardiac silhouette and pulmonary vasculature were normal on the chest roentgenogram. The erythrocyte sedimentation rate was 21 mm/h.
Transthoracic and transesophageal echocardiograms
showed a huge mass localized on the anterior wall of the
right ventricle and atrium. Computed tomography confirmed a mass compressing the right cardiac chambers. The
left ventricular ejection fraction was 62%. Images in cardiac
catheterization showed that the right atrium was considerably compressed by the tumor. Coronary angiography
revealed 30% stenosis of the middle left anterior descending artery and a contrast blush arising from the RCA (Fig 1).
Surgery was planned to resect the tumor. The patient
underwent a median sternotomy. Parietal pericardium
was normal. There was a huge spongy lobulated mass (12
⫻ 9 cm) extending from the right ventricle around the
acute margin of the heart to the ventricular groove
extending up to the aortic root and down to the right
atrial appendix (Fig 2). The mass looked like a dilated
right atrial appendix and was cystic on palpation. After
aortic and bi-caval cannulation, the patient was placed on
cardiopulmonary bypass. The aorta was cross clamped
and the myocardium was arrested by antegrade blood
cardioplegia. Exploration revealed that the tumor was
encasing the RCA 1 cm distal to its origin. The RCA was
transected from the aortic sinus and the supplying arteries of the tumor originating from the RCA were divided.
The tumor was carefully separated from the heart and
complete removal was achieved (Fig 3). The RCA was
reanastomosed to the aortic sinus (Fig 4). The resected
tumor (dimensions, 12 ⫻ 9 ⫻ 6 cm) appeared purplish,
elastic, soft, and multilobular. Pathologic examination
diagnosed the tumor as a cavernous hemangioma.
The patient had an uneventful recovery. She remains
well without medication 14 months postoperatively, and
the echocardiogram showed no recurrence of the tumor.
Ann Thorac Surg
2005;79:1765–7
Fig 1. Tumoral feeders originating from proximal RCA (arrows).
There are feeding arteries, early venous filling, and some tumoral
blush. Stretching of the RCA (by the tumor) early venous fillings
and tumoral blush are also demonstrated.
tomography, or magnetic resonance imaging, but preoperative pathologic diagnosis is not always possible. The
characteristic sign of a cardiac hemangioma on a coronary angiography is a patch of neovascularity termed a
tumor blush. In cardiac hemangiomas, complete resection
is the choice of treatment. The prognosis for hemangio-
Comment
Hemangioma is a benign proliferative lesion characterized by increased endothelial cell turnover. It can be
found anywhere in the body, but most frequently it is
localized to the cervicofacial region [2]. It can be superficial, deep, or visceral in location. Visceral hemangiomas
are frequently located in deeper organs such as the liver,
colon, or brain. Hemangiomas of the heart are extremely
rare tumors with an incidence of 0.0017% at autopsy [3].
The epicardium is the most common location for cardiac
hemangiomas, but they may also be found in the myocardium and endocardium. Histologic appearance may
be either a capillary or cavernous type. The most frequent clinical symptoms depend on the location, size,
and mobility of the tumor. Patients with hemangiomas
may present with dyspnea on exertion, arrhythmias,
angina, sign of right heart failure, pericarditis or pericardial effusion, and thromboembolic events, whereas a
small percent are asymptomatic. Diagnosis of the cardiac
tumors is usually made by echocardiography, computed
Fig 2. Large hemangioma completely overlying the right cardiac
chamber.
Ann Thorac Surg
2005;79:1767–9
CASE REPORT
BOTÍ ET AL
DEEP HYPOTHERMIA FOR SURGERY OF CAROTID ANEURYSM
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topic heart transplantation was described for complete cure
of inoperable tumors. Cardiomyoplasty has also been recommended as an alternative to heart transplantation for
therapy of large ventricular tumors [6]. For our case, the
difficulties encountered were: (1) encasement of the RCA by
the tumor and (2) presence of multiple feeding arteries of
the tumor that originated from the right coronary artery. To
overcome these difficulties we proceeded as follows: After
separating the RCA from its aortic origin, we divided the
supplying arteries. The coronary artery is mobilized completely from the tumor. After resection of the tumor, elongation of the RCA because of stretching the tumor enabled
us to implant it directly into its origin at the RCA. The
surgical technique we have used overcame the difficulty of
the large size and intratumoral course of the RCA so that a
complete resection was possible.
mas is generally favorable with a low recurrence rate.
Moreover, the prognosis of the patients has been quite
good even if they have undergone incomplete resection.
Spontaneous resolution of a large, cavernous hemangioma of the heart at a similar location and size has been
reported in a case after a follow-up of 2 years [4]. For this
particular case, the tumor was deemed unresectable and
a specific therapy has not been prescribed. Regression has
also been reported in extensive unresectable cardiac hemangioma after steroid therapy [5]. Incomplete resection may
result in tumor growth and compression of the coronary
vessels, clinically simulating myocardial infarction, arrhythmia, hemopericardium, and even lethal tamponade. Ortho-
References
1. Brizard C, Latremouille C, Jebara VA, et al. Cardiac hemangiomas. Ann Thorac Surg 1993;56:390 –4.
2. Gampper vascular anomalies. Hemangiomas. Plast Reconstr
Surg 2002;110:572– 85.
3. Strauss R, Merlis R. Primary tumors of the heart. Arch Pathol
1945;39:74.
4. Palmer TE, Tresch DD, Bonchek LI. Spontaneous resolution
of a large, cavernous hemangioma of the heart. Am J Cardiol
1986;58:184 –5.
5. Chang JS, Young ML, Lue HC. Infantile cardiac hemangioendothelioma. Pediatr Cardiol 1992;13:52–5.
6. Chachques JC, Argyriadis PG, Latremouille C, et al. Cardiomyoplasty. Ventricular reconstruction after tumor resection.
J Thorac Cardiovasc Surg 2002;123:889 –94.
Deep Hypothermia and Circulatory
Arrest for Surgery of High
Extracranial Internal Carotid
Aneurysm
Eduardo Tebar Botı́, MD, Iván Martı́n González, MD,
José Ángel Bahamonde, MD,
Juan Martı́nez León, MD, PhD, and
Eduardo Otero Coto, MD, PhD
Service of Cardiovascular Surgery, Hospital Clı́nico
Universitario, Valencia, Spain
A large, high internal carotid artery aneurysm partially
filled with thrombi in a young, 26-year-old male patient
was treated by bypass grafting under deep hypothermia
and circulatory arrest. This approach may be preferable
to other alternatives in patients with high embolic risk
and difficult exposure or inadequate space for distal
carotid artery clamping.
(Ann Thorac Surg 2005;79:1767–9)
© 2005 by The Society of Thoracic Surgeons
Accepted for publication Oct 30, 2003.
Fig 4. Reanastomosis of the right coronary artery to its origin at the
aorta after total excision of the tumor.
© 2005 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Address reprint requests to Dr Otero Coto, Service of Cardiovascular
Surgery, Hospital Clı́nico Universitario, Avda Blasco Ibañez 17, Valencia
46010, Spain; e-mail: [email protected].
0003-4975/05/$30.00
doi:10.1016/j.athoracsur.2003.10.102
FEATURE ARTICLES
Fig 3. Tumor after total excision (probe shows the intratumoral
course of the right coronary artery).