Embolism from a left ventricular myxoma presenting with acute limb ischaemia.

Acute limb ischaemia (ALI) secondary to cardiac myxoma is uncommon. Embolic myxoma should be considered a differential diagnosis in young patients with ALI who do not have apparent cardiovascular risk factors. A multidisciplinary approach and comprehensive care can improve outcomes and optimise the collaborative treatment of ALI. Early referral to a hospital that can provide specialised treatment for ALI helps prevent significant tissue loss and surgical complications, such as amputation.A man in his 20s presented with bilateral ALI of both lower extremities, and an arterial duplex scan revealed a thrombus occluding all arterial segments of the bilateral lower extremities. An intracardiac mass adherent to the apical and anterior interventricular septum on two-dimensional echocardiography suggested a complex myxoma. The patient was diagnosed with ALI Rutherford category III, and bilateral hip disarticulation was performed. The patient was discharged with an anticoagulant.

The evolving role of the total artificial heart in the management of end-stage congenital heart disease and adolescents.

Advances in medical therapies have yielded improvement in morbidity and a decrease in mortality for patients with congenital heart disease, both surgically palliated and uncorrected. An unintended consequence is a cohort of adolescent and adult patients with heart failure who require alternative therapies. One intriguing option is placement of a total artificial heart (TAH) either as a bridge to transplant or as a destination therapy. Of the 1091 Jarvik-7 type TAH (Symbion, CardioWest and SynCardia) placed between 1985 and 2012, only 24 have been performed in patients with congenital heart disease, and a total of 51 were placed in patients younger than 21. At our institution, the SynCardia TAH was implanted in a 19-year-old patient with cardiac allograft failure because of chronic rejection and related multisystem organ failure including need for hemodialysis. Over the next year, she was nutritionally and physically rehabilitated, as were her end organs, allowing her to come off dialysis, achieve normal renal function and eventually be successfully transplanted. Given the continued growth of adolescent and adult congenital heart disease populations with end-stage heart failure, the TAH may offer therapeutic options where previously there were few. In addition, smaller devices such as the SynCardia 50/50 will open the door for applications in smaller children. The Freedom Driver offers the chance for patients to leave the hospital with a TAH, as does the AbioCor, which is a fully implantable TAH option. In this report, we review the history of the TAH and potential applications in adolescent patients and congenital heart disease.

Double papillary fibroelastoma: beautiful, innocent flowers in the left heart.

Papillary fibroelastoma is a rare, benign tumor, and multiple papillary fibroelastomas are even more uncommon. In an asymptomatic patient scheduled for carotid endarterectomy, transthoracic echocardiography discovered a fibroelastoma on the mitral valve. Then, transesophageal echocardiography showed another fibroelastoma on the aortic valve. Because he also needed a right coronary artery bypass, the patient underwent surgical excision of both masses. Fibroelastomas are not always as innocent as they seem, and surgical excision is necessary because of their potential for systemic or coronary embolization. Transoesophageal echocardiography may improve the diagnosis of multiple papillary fibroelastomas.

[Heparin-induced thrombocytopenia occurring after surgical treatment of atrial myxoma--a case report].

INTRODUCTION: Heparin-induced thrombocytopenia (HIT) is an acquired, prothrombotic disorder, caused by antibodies to a complex of heparin and platelet factor 4 (PF4) that activates platelets, resulting in the release of procoagulant microparticles, thrombocytopenia occurrence, generation of thrombin, and frequent thromboses. CASE OUTLINE: We present a case of severe HIT in a 68-year-old female, which occurred after cardiosurgery of the left atrial myxoma with the aim to point out the importance of differential diagnosis of thrombocytopenia in patients recently exposed to heparin. Platelet count dropped on the eleventh postoperative day, six days after unfractioned heparin and enoxaparine threatment, to 4x10(9)/I.The correct diagnosis failed to be made at first. Since thrombocytopenia remained refractory to a corticosteroid treatment and platelet transfusion, the patient was hospitalized on the 13th postoperative day at the Institute of Haematology. The diagnosis of HIT was confirmed with the high-probability clinical score (4T's) and strongly positive anti-heparin-PF4 (PaGIA) test as well as positive platelet aggregation test. The treatment started with a smaller therapeutic doses of danaparoid than recommended of 750 U intravenous bolus and was followed by continuous infusions of 100 U per 1 h and intravenous gammaglobulins in full dosage for four days. The platelet count started to rise on the third day and it was completely normalized on the 5th day of the therapy. CONCLUSION: Treatment of severe HIT with small doses of danaparoid supplemented by intravenous gamma globulin was successful. Additional awareness of heparin-induced thrombocytopenia is needed, especially of HIT in differential diagnosis of thrombocytopenia in patients recently exposed to heparin.

[Recurrent transient ischemic stroke in a young patient with papillary fibroelastoma of the mitral valve and hyperhomocysteinemia. A case report]. / Accidents vasculaires cérébraux ischémiques transitoires récurrents chez une jeune patiente secondaire à un fibroélastome papillaire de la valve mitrale et une hyperhomocystéïnémie. A propos d'une observation.

We describe a case of a young patient admitted for recurrent ischemic stroke caused by a papillary fibroelastoma of the mitral valve and a hyperhomocysteinemia. A papillary fibroelastoma is a benign cardiac tumor which can be associated with serious embolic complications. A moderate plasma level of hyperhomocysteinemia is considered as a risk factor of ischemic stroke. The authors suggest that this association increases the risk of ischemic stroke in their patient. The tumor was surgically removed to avoid new embolic events associated with a vitamin B supplementation. After surgery and acid folic supplementation, no recurrence was observed.

Primary cardiac liposarcoma causing cardiac tamponade: report of a case.

The intracardiac growth and extension of liposarcoma was observed in a 60-year-old woman. The epicardial tumor was identified to originate from the anterior wall of the right ventricle. She initially showed symptoms associated with cardiac tamponade. A surgical operation was performed but it resulted in incomplete resection due to massive invasion and dissemination. The recurrence of the tumors led to congestive heart failure. Finally, she died of heart failure and liver dysfunction as a result of tumor metastasis and invasion. An autopsy detected the primary cardiac liposarcoma. Only a few cases of cardiogenic liposarcoma have so far been reported. A further elucidation of cardiac liposarcoma could reveal mechanisms of the disease, and thus contribute to development of complementary therapies after surgical intervention.

[Diagnosis of a metastatic valvular tumor in a living patient]. / Tumeur métastatique valvulaire diagnostiquée du vivant du malade.

INTRODUCTION: The discovery of an endocardial mass always raises the question of its nature. Infectious endocarditis is the most frequent cause, but others diagnoses must be considered. EXEGESIS: We report a case of endocardial metastasis originating from an upper respiratory tract epidermoid carcinoma in a 48-years-old man. The diagnosis was established while the patient was alive, and survival at the time of writing is 8 months. This case report provides an opportunity for discussion of the differential diagnosis when confronted with an endocardial tumor, i.e. bacterial endocarditis, non-bacterial thrombotic endocarditis, primary cardiac tumors, metastatic osteogenic sarcoma and Libman-Sachs endocarditis. CONCLUSION: Non bacterial thrombotic endocarditis and valvular metastasis should be considered upon discovery of a valvular tumor, in the context of neoplastic disease. The prognosis of endocardial metastasis is poor, but early diagnosis and appropriate management should eventually prolong survival.

[Angiosarcoma of the right atrium: local control via low radiation doses and razoxane. A case report]. / Angiosarkom des rechten Vorhofs: lokale Kontrolle durch niedrige Strahlendosen und Razoxan. Ein Fallbericht.

BACKGROUND: Angiosarcomas of the heart are rare neoplasms bearing an unfavorable prognosis. In recent series, the median survival is about 5 months. The response to radiation therapy is uncertain. CASE REPORT: A 65-year-old copper smith with an angiosarcoma of the right atrium and metastases of the liver received a partial resection of the primary tumor in January 1992. This was followed by a polychemotherapy including ifosfamide, epirubicin and dacarbacin (DTIC). In April 1992, after 5 cycles of this treatment a large regrowth of the primary and multiple pulmonary metastases were observed. After a 4-day pretreatment with the radiosensitizer razoxane, the large tumor of the right heart was irradiated with 25 MV photons of a linear accelerator. Single doses of 200 cGy were given via parallel opposed fields. The total radiation dose at the tumor was 30 Gy. Concomitantly, razoxane was given at a dose of 125 mg twice daily during the radiation days until the end of the radiotherapy. The treatment was well tolerated and the patient went into a subtotal remission. Chest X-rays from September 1992 revealed a progression of the metastases in the lung and the liver, the recurrent tumor of the right atrium remained in a subtotal remission. The patient was retreated with ifosfamide, epirubicin and DTIC. No substantial remission of the metastases occurred and the patient died at the end of January 1993. At autopsy, the recurrent primary and the lung metastases within the region of the former radiation field remained locally controlled. CONCLUSION: Reviewing the literature and considering this case, irradiation seems to be a valid treatment option for the local control of cardiac angiosarcomas. The combination of radiotherapy with razoxane eventually allows a considerable reduction of the radiation dose.

Tratamento cirúrgico de mixoma do coraçäo duplamente recidivado, em paciente testemunha de Jeová: relato de caso / Surgical treatment of recurrent cardiac myxoma in a Jeova's witness patient: case report

A recidiva de mixoma cardíaco após sua remoçao cirúrgica é incomum. Isso se deve à excisao de sua base de implantaçao nas paredes do coraçao. Caso essa ressecçao nao seja ampla, existe a possibilidade da recidiva do tumor. Os autores descrevem o caso de paciente do sexo masculino, 26 anos de idade, com antecedentes de recidiva de mixoma de átrio esquerdo em duas ocasioes e ressecçao com sucesso. O paciente foi admitido em nosso Serviço devido à presença de tumor em átrio esquerdo. O exame ecocardiográfico revelou massa pediculada, localizada no septo interatrial.Por tratar-se de testemunha de Jeová, nao recebeu sangue ou hemoderivados durante todo o tratamento cirúrgico. Na operaçao observou-se massa gelatinosa fixada no septo interatrial. Foi realizada ampla ressecçao do tumor e de sua inserçao no septo. O exame histopatológico constatou tratar-se de mixoma cardíaco.

Cardiopulmonary bypass and cell-saver technique in combined oncologic and cardiovascular surgery.

The purpose of this study was to work out an adequate operative technique for patients with malignant tumors who also need open heart surgery or procedures on major blood vessels. We had 8 such patients. In 6 of them, a tumor (3 cases hypernephroid cancer and 3 cases retroperitoneal sarcoma) had grown through the inferior vena cava (IVC) up to the right atrium. Two patients had lung cancer together with severe coronary artery disease. All of these patients were operated on using a heart-lung machine (HLM) and cell saver (CS). In 6 patients the intravascular portion of the tumor was extracted as much as possible through a right atrium approach (in 3 cases a nephrectomy was performed). Two patients had a one-stage coronary artery bypass graft (CABG) and a lobectomy. All of the patients had uneventful postoperative periods and were alive when checked on 1 year after the procedures. During cytological investigation after each operation, tumor cells were found only on the internal surface of the HLM arterial filters with 20 microns holes. We suggest that special cardiovascular devices such as the HLM and CS might be used in borderline situations in oncology without increasing the risk of hematogenous tumor dissemination.