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CARDIAC SURGERY _____________________________________________________

Acute Leriche Syndrome Due to Sarcoma of Left Atrium Chenming Ma, M.D., Baris Tutkun, M.D., Horst Laube, M.D., Ph.D., Katharina Wassilew, M.D., Natalia Solowjowa, M.D., and Roland Hetzer, M.D., Ph.D. Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany doi: 10.1111/jocs.12487 (J Card Surg 2015;30:513–514)

Figure 1. (A) CT scan in early arterial phase shows a total occlusion of the abdominal aorta including celiac trunk, superior mesenteric artery, renal arteries, and left common iliac artery. 1: embolus in left atrium, 2: celiac trunk, 3: superior mesenteric artery, and 4: emboli in abdominal aorta and left common iliac artery. (B) The 3D reconstruction of the late arterial phase of the CT scan shows the occlusion of the abdominal aorta. There is reconstitution of the common femoral arteries bilaterally via circumflex iliac and inferior epigastric arteries (arrowheads). (C) Transesophageal two-dimensional echocardiography demonstrates a large mass in the left atrium (*) and another attached to the leaflet of the mitral valve which extends into the left ventricle during diastole (**). LA, left atrium; LV, left ventricle.

C. Ma and B. Tutkun contributed equally to this article. Conflict of interest: The authors acknowledge no conflict of interest in the submission. Disclosures: Authors have nothing to disclose with regard to commercial support. Address for correspondence: Horst Laube, M.D., Ph.D., Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. Fax: þ49 30 4593 2026; e-mail: [email protected]

A previously healthy 18-year-old male was admitted with acute abdominal pain and bilateral lower extremity paresis. A computed tomography (CT) scan of the abdomen revealed a total occlusion of the abdominal aorta including the celiac trunk, superior mesenteric artery, both renal arteries, and the left common iliac artery (Fig. 1A, B). Transesophageal echocardiography demonstrated two left atrial masses, one of which was attached to the leaflet of the mitral valve and which

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J CARD SURG 2015;30:513–514

Figure 2. (A) High power view (HE,  20) showing typical example of the solid tumor area. (B) High power view (HE,  20) showing undifferentiated sarcoma cells infiltrating the atrial muscle wall (*). Multinucleated sarcoma cells are present (arrowheads). (C) Smooth muscle actin (a-SMA) showing focal expression of SMA (#) of sarcoma cells compared with blood vessels (arrows) as positive control. (D) Ki-67 (proliferation index) exhibiting 20–30% of the tumor cells.

extended into the left ventricle during diastole (Fig. 1C). A median sternotomy and left thoracoabdominal incision were made and a 4.8  3.0  3.0 cm embolic mass was removed from the abdominal aorta and another more distal 4.0  2.4  1.4 cm mass was extracted using Fogarty catheters. The patient was then placed on cardiopulmonary bypass and the two left atrial masses were removed without any injury to the mitral valve. The patient tolerated the procedure well

and a postop echo one month following the surgery showed no mitral regurgitation and no recurrence of tumor. All the masses were consistent with a grade 3 undifferentiated spindle cell sarcoma (Fig. 2). Acknowledgment: The authors thank Ms. Anne M. Gale, Editor in the Life Sciences of the DeutschesHerzzentrum Berlin, for fruitful discussions during the preparation of the manuscript.

Acute leriche syndrome due to sarcoma of left atrium.

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