Ischemic stroke and incidental finding of a right atrial lipoma.

A young man presented with recurrent ischemic stroke under antiplatelet therapy. A patent foramen ovale (PFO) was diagnosed by transesophageal echocardiography (TEE) and the patient was referred to our institution for percutaneous closure. An echogenic mass in the right atrium was detected during the intraprocedural TEE. The interventional team decided to perform transcatheter closure of PFO under fluoroscopy and TEE guide, without complications. Subsequent cardiac magnetic resonance (CMR) imaging confirmed an encapsulated and hyperintense mass located in the roof of the right atrium. The signal intensity pattern and the absence of gadolinium contrast uptake allowed a confident diagnosis of lipoma. Cardiac lipoma accounts for about 10% of primary cardiac tumors and frequently rises from the epicardial fat tissue. Echocardiographic images can remain equivocal about the nature of the mass and CMR offers a substantial contribution to a correct diagnosis. The tumor usually appears encapsulated and asymptomatic, but dyspnea, atrial and ventricular arrhythmias and, rarely, peripheral embolization have been reported. To our knowledge, this is the second case reported on paradoxical embolization associated with right atrial lipoma. Although the relationship of cardiac lipoma with stroke is not well defined, the potential proembolic significance of this lesion cannot be excluded, especially when a PFO coexists.

Cutting balloon angioplasty in percutaneous carotid interventions.

PURPOSE: To report a prospective feasibility study of cutting balloon angioplasty (CBA) applied in the predilation phase of carotid artery stenting (CAS) in highly calcified lesions. METHODS: From January 2003 to February 2007, 178 consecutive patients (109 men; mean age 73.1+/-7.3 years) with highly calcified carotid lesions underwent CAS with CBA applied as a pre-specified strategy in the predilation phase of the procedure. All steps in the procedure were performed under cerebral filter protection. The cutting balloon ranged in diameter from 3 to 4 mm and was inflated at nominal pressures in the target lesion. Pre-CBA dilation with a low-profile coronary balloon was performed only when the cutting balloon was not able to cross the lesion. Selection of the filters and stents was at the operator's discretion. Primary endpoints were the all stroke and death rates at 30 days and 6 months. Secondary endpoints included cutting balloon success (positioning and full balloon inflation), CAS technical success (residual angiographic stenosis <30%), CAS procedural success (technical success and no complications), and in-hospital major complications. RESULTS: Cutting balloon success was achieved in all 178 patients. In 32 (18.0%), pre-CBA dilation was necessary due to inability to cross the lesion with the cutting balloon initially. CAS technical success was achieved in all patients. One (0.6%) patient suffered transient neurological intolerance due to flow cessation from massive debris in the distal filter; this event was completely resolved after the filter was removed (CAS procedural success 99.4%). One patient suffered a major stroke at day 15 (0.6% 30-day all stroke and death rate). At the 6-month follow-up, 174 (97.7%) patients were evaluated; 1 patient died from myocardial infarction at day 35, and 2 patients died from non-neurological or cardiac causes at days 103 and 158. The cumulative all stroke and death rate was 2.2%. CONCLUSION: These data suggest that CBA performed during the predilation phase of CAS in highly calcified lesion is a safe and useful method to prepare this lesion subset for stenting.