Although the roentgenographic changes due to pulmonary sarcoidosis may resolve completely in a large percentage of cases, probably 20 percent will ultimately develop widespread fibrosis with eventual distortion of the lung a r c h i t e ~ t u r e This . ~ distortion is caused by a gradual upward migration of parenchymal lesions over a period of years, which results in dense fibrosis with upward retraction of the hila.' Coarse, irregular strands commonly extend from the hila toward the periphery. The presence of a mass lesion simulating bronchogenic carcinoma is an unusual finding, and was not mentioned in a series of 1,254 patients with proven sarcoidosis, 94 percent of whom had abnormal chest roentgenog r a m ~ On . ~ reviewing the literature we could find only four cases similar to Hahn's6 patient was found to have multiple hard, dense nodules which resulted in a "frozen hilus." Multiple biopsies of the lung, hilar mass, and pleural implants were suggestive of sarcoidosis. Resectional surgery was deemed inadvisable, and the patient remained well for 11 years after operation without further specific therapy. Sarcoidosis commonly causes symptoms which are also usually associated with bronchogenic carcinoma, including fatigue, malaise, weight loss, cough, dyspnea, chest pain, and occasionally hemoptysis.3 When these are combined with suspicious chest roentgenogram, planigrams, bronchoscopic findings, and bronchograms, the clinical suspicion of carcinoma is even stronger. Since bronchogenic carcinoma has been reported to co-exist with sarcoidosis,s-" even if the diagnosis of sarcoidosis has been M y established previously, diagnostic thoracotomy will be required to rule out co-existent carcinoma. The finding of bronchial stenoses in o w patient contributed further to the suspicion of carcinoma. Three different types of bronchial involvement have been described in sarcoidosis.1?,13 The first is caused by enlarged hilar nodes which compress the major bronchi and which may result in collapse or eventual bronchiectasis. This is quite rare, in spite of frequent massive enlargement of the mediastinal nodes. The second type is the occurrence of sarcoid lesions in the bronchial wall. This type is not unusual and diagnosis can frequently be made by means of bronchoscopic biopsy.l2-l5 The third type is the diffuse bronchial constriction which occurs in the later stages of fibrosis and results in narrowing of the major bronchi. Longcope and Freiman4 suggest that this is not infrequent. ACKNOWLEDGMENT: The authors express their appreciation to the Department of Medical Communications of the Alton Ochsner Medical Foundation for assistance in preparation of the manuscript.
1 Siltzbach LE: Sarcoidosis: Clinical features and management. Med Clin N Am 51:483-502, 1967
2 Fraser RG, Pare JAF': Diagnosis of Diseases of the Chest (vol2). Philadelphia, Saunders, 1970, pp 1090-1091 3 Mayock RL, Bertrand P, Morrison CB, et al: Manifesta-
CHEST, 67: 6, JUNE, 1975
tions of sarcoidosis: Analysis of 145 patients with a review of 9 series selected from the literature. Am J Med 35 :67-89, 1963 4 Longcope W, Freirnan DC:A study of sarcoidosis based on combined investigation of 160 cases including 30 autopsies from Johns Hopkins Hospital and Massachusetts General Hospital. Medicine 31: 1-132, 1952 5 Siltzbach LE, Som ML: Sarcoidosis with bronchial involvement. Mt Sinai J Med (NY) 19:473-480, 1953 6 Hahn R: Unusual forms of sarcoidosis. South Med J 64: 541645,1971 7 Westcott JL, Noehren TH: Bronchial stenosis in chronic sarcoidosis. Chest 63:893-897,1973 8 Sakula A: Bronchial carcinoma and sarcoidosis. Br J Cancer 17:206-212,1963 9 Jefferson M, Smith WT, Taylor AB, et al: A report of 2 cases of sarcoidosis with brochial carcinoma. Thorax 9:291-298, 1954 10 Ellman P, Hanson A: The co-existence of bronchial carcinoma and sarcoidosis. Br J Tuberc 52:218-221, 1958 11 Sarkar TK: Anaplastic carcinoma of the lung and sarcoidosis. Br J Clin Pract 24:297-299, 1970 12 Honey M, Jepson E: Multiple bronchostenoses due to sarcoidosis. Report of 2 cases. Br J Med 2: 1330-1334, 1957 13 Kalbian W: Bronchial involvement in pulmonary sarcoidosis. Thorax 12:18-23,1957 14 Friedman OH, Blaugrund SM, Siltzbach LE: Biopsy of the bronchial wall as an aid in diagnosis of sarcoidosis. JAMA 183:646-850, 1963 15 Siltzbach LE, Cahn LR: Random biopsy of bronchial and palatal mucosa in the diagnosis of sarcoidosis. Acta Med Scand Suppl425:230-236, 1964
A Technique for Unknotting an lntracardiac Flow-Directed Balloon catheter* Harry G. Mond, M.D.;" Dwight W. Clark, M.D., F.C.C.P.;? Stuart 1. Nesbitt, B.A.;$ and Robert C. Schlont, M.D.11
Described is an unusual complication occurring during right-sided cardiac catheterization using a 7F flow-directed balloon catheter. During an attempt to direct the catheter from the main pulmonary artery into the pulmonary wedge position, the tip became entangled in a loop of catheter and knotted. Initially, all attempts to unkad or remove the catheter faikd. A movable-core guide wire was passed through the major lumen of the catheter, resulting in the immediate unkn~ttingof the catheter, thus allowing its withdrawal. 'From the Cardiolo Division, Department of Medicine, Emory University ~%oolof Medicine and Grady Memorial Hospital, Atlanta, Ga. "Fellow in Medicine ( Cardiology). +Assistant Professor of Medicine ( Cardiology). $Technician, Cardiovascular Laboratory. I I Director, Division of Cardiology. Su ported in part by NHLI Training grant nos. HE5653 an8 HE-05731. Reptint requests: Dr. Schlont, 69 Butler Street, SE, Atlanta
30303
UNKNOTTIN6 INTRACARDIAC FLOW-DIRECTED BALLOON CATHETER 731
I
n recent years the flow-directed balloon-tipped catheter has become an important instrument in the assessment of cardiac hernadynamics.l~a Knotting of these catheters is very unusual,a and the described method of withdrawal with the knot intact cannot be performed with the newer larger diameter catheters,' We describe here a potentially severe complication occurring with a 7F flow-directed nonthermdilution catheter, that was averted when the catheter was easily wknatted, using a movable care guide wire.
A 45 year old woman with aortic regurgitation of unknawn etiology underwent cardiac catheterization prior to meideration for aortic valve mplacament. A 7F Swan-Ganz nonthermodilution flow-directed balloon catheter was imerted into the right basilic vein fram a right antecubital fosaa cutdown, The balloon was Mated in the superior vena cave and the catheter directed without clifRculty through what appeared to be a normal-sized right atrium and right ventricle and entered the proximal part of the main pulmonary artery. However, the catheter would not progress beyond thig position and a partial Imp with a large diameter then developed in the right atrium and rlght ventricle. At thk point, the tip of the catheter nlipged back into the right ventricular outflow tract. With the intention of pulling the catheter back ts the right aMum, the ballmn waa detlated and the catheter withdrawn. Fsllowlnp withdrawal of the catheter Into the right atrium, it wea noted that a large lkee complete knot had formed about 18 cm from the tip. The catheter was manipulated into numeroun gaeitiona bath in the right atrium and right ventricle, but it co~ddnot be unknotted. The catheter waa then withdrawn, resulttng in tightening of the knat. Because of the large diameter and sWness of the catheter, the knot remained much larger than the diameter of the peripheral veins and could not be completely withdrawn. A USCI Q.038 inch (Q.B7 mm) rnovablacore guide wire waa then dlmcted along the majar lumen of the catheter, with about 6 cm of the lnner core withdrawn from the guide wire tip. Aa the flappy tip of the guide wire approached the knot, it lea~end.It waa intended that the adjustable lnner core bs used to sWen the distal part of the guide wire and ea further leasen the knat. However, before the inner core could be manipulated, the catheter unknatted and waa removed from the vein, The right heart satheter wa9 r e p l a d and the cardiac catheterization g r m d d uneventfully.
Intracardiac knotting of catheters, although reportedly uncommon, dms represent an important complication with the use of the flexible polyvinyl chloride flow-directed ballaan catheten, The manufacturers of the SwanCanz catheter, Edwards Laboratories, stress that kinking and looping, the precursors of knotting, occur when an excessive length of catheter ha9 been inserted, In such an event, the catheter should be carefully withdrawn to the 30 crn mark and then readvanced. In our case, the looping was recognized immediately and the recornmended procedure instituted but, unfomately, knatting still occurred. Because of the large luminal cross
sectional area of the 747 catheter ( 1,A rnml ) "he catheter with knot intact could not be withdrawn fram the vein, a techniclue recommended for the 5P catheter, by Lipp et al.4 If the catheter h inserted from the subclavian vein, withdrawal with the hiot intact is also not recommended as, theoretically, it may lacerate this vein, with resultant urlcontrollable hemorrhage," Another method for unknatting catheters involves manipulation in the right atrium or right ventricle in order to loosen and move the knat toward and over the catheter tip. Although sueeessM on weasion,@it was not helpful in our case, Both local cutdown on venous channels' and open cadiotamy" have also been used on rare accasims to remove knotted catheters, although the use of a guide wire to unknot a catheter appears to be a logical maneuver, we are unaware of its description with this complication, Baldi et a l v e e l that the passage of a semiflexible guide wire through the lumen of a catheter is ineffective in complete knotting and is contraindicated because of the theoretical hazard of perforating the catheter, blood vessels or cardiac chamber. We feel, however, that provided tho knot is not tight, this technique should not introduce an extra hazard to the patient. In our case a 0.038 inch movable-core guide wire was used with minimal difficulty most of the way along the lumen of the catheter, On testing other 7P nonthermadilution Swm-Ganz catheters with this guide wire, considerable difaculiy was found in its passage. However, a thinner 0.035 inch movable-care guide wire was used without difscdty to the tip sf the catheter. We recommend that both sims, or at least a 0.035inch guide wire be available whenever a s h e 7P Swan-Canz nanthermodilution catheter is used, The use of such a guide wire should obviously be performed under fluorascopis control ta prevent the possibility of perforation of catheter, blood vessels or cardiac chamber, In cmclusion, the incidence of serious complications with the use of flow-directed balloon catheters is rare in relationship ta the utilization of this device.10 Nevertheless, extreme care must always be practiced and the physician must be aware of all the potential dangers, their prevention md their treatment.
1 Swan HJC, Ganz W, Forrenter J, st el: Catheterization of the heart in man with the use of a flaw-directed balloontipped catheter. N Engl J Med 283:447-451, 1978 2 Mond H 6 , Hunt D,Slsrnan G:Haemdynamic monitoring in the m m r y care, unit using the Swan-Ganz right heart catheter, Br Heart J 35:W-842, 1973 3 The Pathbder Psmily of Swan-Gam Flow Directed Right Heart Catheters. Paduct informatltm. 8mta Ana, Calif, Edwards Laboratories, 1873 4 Llpp H, B'hnoghue K, Rmnekov L: Inkaeardiae knotting of a flow-directed balloon catheter. N Engl J Med 284 :220, 1871 5 Sahl GH, Bramwit DN: Removal of a knotted subclavian and aerni8oating pacing wire, Chest 62:694-1Q72 6 Swan HJC: Complicatiom related to equipment fallure. Circulation ( Sum1 3 ) 37:57-58, 1W
CHEST, 67: 6, JUNE, 1975
7 Swaroop S: Knotting of two central venous monitoring catheters. Am J Med 53:386-388,1972 8 Skinner JF, Burroughs JT: Intracardiac knotting of the catheter during right heart catheterization. Circulation 23:Bl-83,1961 9 Baldi J, Fishenfeld J, Benchimol A: Complete knotting of a catheter and a nonsurgical method of removal. Chest 65:93-95, 1974 10 Swan HJC, Ganz W: Guidelines for use of balloon-tipped catheter. Am J Cardiol 34:119, 1974
*
Recurrent Myxosarcoma ,of Left Atrium
William R. C. Murphy, M.D.; ** John B. Carter, M.D.;t RusseU V. Lucas, M.D.;f James H. MoUer, M.D.;f Jesse E. Edwards, M.D.;? and Aldo R. Castaneda, M.D., F.C.C.P.5
The surgical treatment of cardiac myxosarcoma is reviewed with emphasis placed on palliative response to radiation therapy. A ease of primary myxosarcoma of the left atrium in a 16-year-old girl is presented. The 'From the Departments of sGgery, Pathology and Pediatrics, University of Minnesota, Minneapolis; from the Department of Pathology United Hospital-Miller Division, St. Paul: and from the De~artmentof Surnew. - , Children's ~ospital'Medical Center, &ton. This study was supported by Public Health Service Grant No. 5 R01 HL-05694 and Research Training Grant No. 5 TO1 HL-05570 from the National Heas and Lunn Institute. . .- "Department of Sur ery, Universi of Minnesota. ?Department of ~ a g o l o ~ yUnite2 , Hospital-Miller Division. f Department of Pediatrics, University of Minnesota. §Department of Surgery, Children's Hospital Medical Cen- . - ter,-Boston. Reprint requests: Dr. Castanedu, Department of Surgery, Children's 'Hospital Medical Center, Boston 02115
-
-
-
tumor was surgically removed in October, 1967. Recurrently myxosarcoma was removed in August, 1968, at which time involvement of the pulmonary veins and the pericardium was noted. Subsequent to postoperative radiation therapy, the patient remained symptom-free for more than three year& Death occurred 4% years after the original operation from local and systemic recurrence of the tnmor.
This
is a report of a patient with left atrial myxosarcoma treated by surgical and radiation therapy .with a brief summary of the literature on the subject, stressing the need to combine both types of therapy.
The patient, a 16-year-old girl, was admitted with the chief complaint of marked increase in shortness of breath during late 1967. On physical examination, she had to remain sitting upright in bed. A blowing systolic nonradiating murmur, grade 2/6, best heard at the cudiac apex, was present. The cervical veins were distended to the angle of the jaw when the patient was sitting. The liver was percussed 3 cm below the right costal margin. Thoracic roentgenograms showed pulmonary edema and a relatively small cardiac silhouette. The electrocardiogram had ST changes compatible with ischemia, myocarditis or digitalis effect. Selective pulmonary arteriography showed an enlarged main pulmonary artery and a large filling defect, 3 by 6 cm, within the left atrium. The left ventriculogram exhibited moderate r d u x of contrast medium into the left atrium with a large 6lling defect outlined within the atrium which at times seemed to prolapse through the mitral valve. The patient was taken to the operating room and via a right anterolateral thoracotomy, the left atrium was found to be enlarged by a mass that pushed down the intra-atrial sulcus. On total cardiopulmonary bypass, the left atrium was
FIGURE s. a. necurrent tumor nodules involving posterior aspect 01 ~ureseptal wall of the left atrium. Area of septal patch ( P ) is anterior to recurrent tumor. b. Closeup of tumor involving the posterior leaflet of the mitral valve.
CHEST, 67: 6, JUNE, 1975
RECURRENT MYXOSARCOMA OF LEFT ATRIUM 733
1 Siltzbach LE: Sarcoidosis: Clinical features and management. Med Clin N Am 51:483-502, 1967
2 Fraser RG, Pare JAF': Diagnosis of Diseases of the Chest (vol2). Philadelphia, Saunders, 1970, pp 1090-1091 3 Mayock RL, Bertrand P, Morrison CB, et al: Manifesta-
CHEST, 67: 6, JUNE, 1975
tions of sarcoidosis: Analysis of 145 patients with a review of 9 series selected from the literature. Am J Med 35 :67-89, 1963 4 Longcope W, Freirnan DC:A study of sarcoidosis based on combined investigation of 160 cases including 30 autopsies from Johns Hopkins Hospital and Massachusetts General Hospital. Medicine 31: 1-132, 1952 5 Siltzbach LE, Som ML: Sarcoidosis with bronchial involvement. Mt Sinai J Med (NY) 19:473-480, 1953 6 Hahn R: Unusual forms of sarcoidosis. South Med J 64: 541645,1971 7 Westcott JL, Noehren TH: Bronchial stenosis in chronic sarcoidosis. Chest 63:893-897,1973 8 Sakula A: Bronchial carcinoma and sarcoidosis. Br J Cancer 17:206-212,1963 9 Jefferson M, Smith WT, Taylor AB, et al: A report of 2 cases of sarcoidosis with brochial carcinoma. Thorax 9:291-298, 1954 10 Ellman P, Hanson A: The co-existence of bronchial carcinoma and sarcoidosis. Br J Tuberc 52:218-221, 1958 11 Sarkar TK: Anaplastic carcinoma of the lung and sarcoidosis. Br J Clin Pract 24:297-299, 1970 12 Honey M, Jepson E: Multiple bronchostenoses due to sarcoidosis. Report of 2 cases. Br J Med 2: 1330-1334, 1957 13 Kalbian W: Bronchial involvement in pulmonary sarcoidosis. Thorax 12:18-23,1957 14 Friedman OH, Blaugrund SM, Siltzbach LE: Biopsy of the bronchial wall as an aid in diagnosis of sarcoidosis. JAMA 183:646-850, 1963 15 Siltzbach LE, Cahn LR: Random biopsy of bronchial and palatal mucosa in the diagnosis of sarcoidosis. Acta Med Scand Suppl425:230-236, 1964
A Technique for Unknotting an lntracardiac Flow-Directed Balloon catheter* Harry G. Mond, M.D.;" Dwight W. Clark, M.D., F.C.C.P.;? Stuart 1. Nesbitt, B.A.;$ and Robert C. Schlont, M.D.11
Described is an unusual complication occurring during right-sided cardiac catheterization using a 7F flow-directed balloon catheter. During an attempt to direct the catheter from the main pulmonary artery into the pulmonary wedge position, the tip became entangled in a loop of catheter and knotted. Initially, all attempts to unkad or remove the catheter faikd. A movable-core guide wire was passed through the major lumen of the catheter, resulting in the immediate unkn~ttingof the catheter, thus allowing its withdrawal. 'From the Cardiolo Division, Department of Medicine, Emory University ~%oolof Medicine and Grady Memorial Hospital, Atlanta, Ga. "Fellow in Medicine ( Cardiology). +Assistant Professor of Medicine ( Cardiology). $Technician, Cardiovascular Laboratory. I I Director, Division of Cardiology. Su ported in part by NHLI Training grant nos. HE5653 an8 HE-05731. Reptint requests: Dr. Schlont, 69 Butler Street, SE, Atlanta
30303
UNKNOTTIN6 INTRACARDIAC FLOW-DIRECTED BALLOON CATHETER 731
I
n recent years the flow-directed balloon-tipped catheter has become an important instrument in the assessment of cardiac hernadynamics.l~a Knotting of these catheters is very unusual,a and the described method of withdrawal with the knot intact cannot be performed with the newer larger diameter catheters,' We describe here a potentially severe complication occurring with a 7F flow-directed nonthermdilution catheter, that was averted when the catheter was easily wknatted, using a movable care guide wire.
A 45 year old woman with aortic regurgitation of unknawn etiology underwent cardiac catheterization prior to meideration for aortic valve mplacament. A 7F Swan-Ganz nonthermodilution flow-directed balloon catheter was imerted into the right basilic vein fram a right antecubital fosaa cutdown, The balloon was Mated in the superior vena cave and the catheter directed without clifRculty through what appeared to be a normal-sized right atrium and right ventricle and entered the proximal part of the main pulmonary artery. However, the catheter would not progress beyond thig position and a partial Imp with a large diameter then developed in the right atrium and rlght ventricle. At thk point, the tip of the catheter nlipged back into the right ventricular outflow tract. With the intention of pulling the catheter back ts the right aMum, the ballmn waa detlated and the catheter withdrawn. Fsllowlnp withdrawal of the catheter Into the right atrium, it wea noted that a large lkee complete knot had formed about 18 cm from the tip. The catheter was manipulated into numeroun gaeitiona bath in the right atrium and right ventricle, but it co~ddnot be unknotted. The catheter waa then withdrawn, resulttng in tightening of the knat. Because of the large diameter and sWness of the catheter, the knot remained much larger than the diameter of the peripheral veins and could not be completely withdrawn. A USCI Q.038 inch (Q.B7 mm) rnovablacore guide wire waa then dlmcted along the majar lumen of the catheter, with about 6 cm of the lnner core withdrawn from the guide wire tip. Aa the flappy tip of the guide wire approached the knot, it lea~end.It waa intended that the adjustable lnner core bs used to sWen the distal part of the guide wire and ea further leasen the knat. However, before the inner core could be manipulated, the catheter unknatted and waa removed from the vein, The right heart satheter wa9 r e p l a d and the cardiac catheterization g r m d d uneventfully.
Intracardiac knotting of catheters, although reportedly uncommon, dms represent an important complication with the use of the flexible polyvinyl chloride flow-directed ballaan catheten, The manufacturers of the SwanCanz catheter, Edwards Laboratories, stress that kinking and looping, the precursors of knotting, occur when an excessive length of catheter ha9 been inserted, In such an event, the catheter should be carefully withdrawn to the 30 crn mark and then readvanced. In our case, the looping was recognized immediately and the recornmended procedure instituted but, unfomately, knatting still occurred. Because of the large luminal cross
sectional area of the 747 catheter ( 1,A rnml ) "he catheter with knot intact could not be withdrawn fram the vein, a techniclue recommended for the 5P catheter, by Lipp et al.4 If the catheter h inserted from the subclavian vein, withdrawal with the hiot intact is also not recommended as, theoretically, it may lacerate this vein, with resultant urlcontrollable hemorrhage," Another method for unknatting catheters involves manipulation in the right atrium or right ventricle in order to loosen and move the knat toward and over the catheter tip. Although sueeessM on weasion,@it was not helpful in our case, Both local cutdown on venous channels' and open cadiotamy" have also been used on rare accasims to remove knotted catheters, although the use of a guide wire to unknot a catheter appears to be a logical maneuver, we are unaware of its description with this complication, Baldi et a l v e e l that the passage of a semiflexible guide wire through the lumen of a catheter is ineffective in complete knotting and is contraindicated because of the theoretical hazard of perforating the catheter, blood vessels or cardiac chamber. We feel, however, that provided tho knot is not tight, this technique should not introduce an extra hazard to the patient. In our case a 0.038 inch movable-core guide wire was used with minimal difficulty most of the way along the lumen of the catheter, On testing other 7P nonthermadilution Swm-Ganz catheters with this guide wire, considerable difaculiy was found in its passage. However, a thinner 0.035 inch movable-care guide wire was used without difscdty to the tip sf the catheter. We recommend that both sims, or at least a 0.035inch guide wire be available whenever a s h e 7P Swan-Canz nanthermodilution catheter is used, The use of such a guide wire should obviously be performed under fluorascopis control ta prevent the possibility of perforation of catheter, blood vessels or cardiac chamber, In cmclusion, the incidence of serious complications with the use of flow-directed balloon catheters is rare in relationship ta the utilization of this device.10 Nevertheless, extreme care must always be practiced and the physician must be aware of all the potential dangers, their prevention md their treatment.
1 Swan HJC, Ganz W, Forrenter J, st el: Catheterization of the heart in man with the use of a flaw-directed balloontipped catheter. N Engl J Med 283:447-451, 1978 2 Mond H 6 , Hunt D,Slsrnan G:Haemdynamic monitoring in the m m r y care, unit using the Swan-Ganz right heart catheter, Br Heart J 35:W-842, 1973 3 The Pathbder Psmily of Swan-Gam Flow Directed Right Heart Catheters. Paduct informatltm. 8mta Ana, Calif, Edwards Laboratories, 1873 4 Llpp H, B'hnoghue K, Rmnekov L: Inkaeardiae knotting of a flow-directed balloon catheter. N Engl J Med 284 :220, 1871 5 Sahl GH, Bramwit DN: Removal of a knotted subclavian and aerni8oating pacing wire, Chest 62:694-1Q72 6 Swan HJC: Complicatiom related to equipment fallure. Circulation ( Sum1 3 ) 37:57-58, 1W
CHEST, 67: 6, JUNE, 1975
7 Swaroop S: Knotting of two central venous monitoring catheters. Am J Med 53:386-388,1972 8 Skinner JF, Burroughs JT: Intracardiac knotting of the catheter during right heart catheterization. Circulation 23:Bl-83,1961 9 Baldi J, Fishenfeld J, Benchimol A: Complete knotting of a catheter and a nonsurgical method of removal. Chest 65:93-95, 1974 10 Swan HJC, Ganz W: Guidelines for use of balloon-tipped catheter. Am J Cardiol 34:119, 1974
*
Recurrent Myxosarcoma ,of Left Atrium
William R. C. Murphy, M.D.; ** John B. Carter, M.D.;t RusseU V. Lucas, M.D.;f James H. MoUer, M.D.;f Jesse E. Edwards, M.D.;? and Aldo R. Castaneda, M.D., F.C.C.P.5
The surgical treatment of cardiac myxosarcoma is reviewed with emphasis placed on palliative response to radiation therapy. A ease of primary myxosarcoma of the left atrium in a 16-year-old girl is presented. The 'From the Departments of sGgery, Pathology and Pediatrics, University of Minnesota, Minneapolis; from the Department of Pathology United Hospital-Miller Division, St. Paul: and from the De~artmentof Surnew. - , Children's ~ospital'Medical Center, &ton. This study was supported by Public Health Service Grant No. 5 R01 HL-05694 and Research Training Grant No. 5 TO1 HL-05570 from the National Heas and Lunn Institute. . .- "Department of Sur ery, Universi of Minnesota. ?Department of ~ a g o l o ~ yUnite2 , Hospital-Miller Division. f Department of Pediatrics, University of Minnesota. §Department of Surgery, Children's Hospital Medical Cen- . - ter,-Boston. Reprint requests: Dr. Castanedu, Department of Surgery, Children's 'Hospital Medical Center, Boston 02115
-
-
-
tumor was surgically removed in October, 1967. Recurrently myxosarcoma was removed in August, 1968, at which time involvement of the pulmonary veins and the pericardium was noted. Subsequent to postoperative radiation therapy, the patient remained symptom-free for more than three year& Death occurred 4% years after the original operation from local and systemic recurrence of the tnmor.
This
is a report of a patient with left atrial myxosarcoma treated by surgical and radiation therapy .with a brief summary of the literature on the subject, stressing the need to combine both types of therapy.
The patient, a 16-year-old girl, was admitted with the chief complaint of marked increase in shortness of breath during late 1967. On physical examination, she had to remain sitting upright in bed. A blowing systolic nonradiating murmur, grade 2/6, best heard at the cudiac apex, was present. The cervical veins were distended to the angle of the jaw when the patient was sitting. The liver was percussed 3 cm below the right costal margin. Thoracic roentgenograms showed pulmonary edema and a relatively small cardiac silhouette. The electrocardiogram had ST changes compatible with ischemia, myocarditis or digitalis effect. Selective pulmonary arteriography showed an enlarged main pulmonary artery and a large filling defect, 3 by 6 cm, within the left atrium. The left ventriculogram exhibited moderate r d u x of contrast medium into the left atrium with a large 6lling defect outlined within the atrium which at times seemed to prolapse through the mitral valve. The patient was taken to the operating room and via a right anterolateral thoracotomy, the left atrium was found to be enlarged by a mass that pushed down the intra-atrial sulcus. On total cardiopulmonary bypass, the left atrium was
FIGURE s. a. necurrent tumor nodules involving posterior aspect 01 ~ureseptal wall of the left atrium. Area of septal patch ( P ) is anterior to recurrent tumor. b. Closeup of tumor involving the posterior leaflet of the mitral valve.
CHEST, 67: 6, JUNE, 1975
RECURRENT MYXOSARCOMA OF LEFT ATRIUM 733
