Giant Ilhan
Blood
Cyst
PASAOGLU, M.D.,
of
Riza
the
Left
Ventricle
DOGAN, M.D.,
Filiz OZYILMAZ, M.D.,**
Aysel
and A. Yuksel
ORAM, M.D.,*
BOZER, M.D.
SUMMARY A case of a giant blood cyst within the left ventricle of a 34-year-old man is presented with a brief review of the literature and a discussion of the pathogenesis. Additional Blood cyst
B
LOOD ser
Indexing Words: Mitral valve
cysts in
on the
l844,1)
heart
and
valves
were
subsequently
observers
quent single
necropsy findings in infants under blood cyst, large enough to produce In
cyst
has been the
was
stressed
infrequently
following
case,
successfully
that
small
from
in
of the
time
1857.2)
cardiac
by Elsas-
Since valves
then
are
fre-
6 months of age.3)-5) However a clinical symptoms in older children in the literature.
a 34-year-old
removed
for the first
Luschka
cysts
reported
circulation
reported
by
many
or adults
have
Extracorporeal
the
male
patient
anterior
mitral
whose
giant
papillary
blood
muscle
is
presented.
CASE REPORT A 34-year-old of Medicine tient's
on
main
epigastric
man
was
February
5,
complaints area
For
2 months
He
was
had
been
treated told
relieved he had with
were
admitted
a beta
by his physician
The
gnawing,
by food noted
to the
1990. but
dyspnea
aching, recurring on exertion
receptor that
Hacettepe
past
blocker
it would
University,
history
revealed
soreness
and
an
or so after
hour and
and
be better
for him
the
burning
paroxysmal antacid.
Faculty
that
pa-
in the a meal.
coughing. However,
he
to be admitted
From the Department of Thoracic and Cardiovascular Surgery, Hacettepe University, Faculty of Medicine, Hacettepe, Ankara, Turkey. *Professor , Department of Internal Medicine (Cardiology Unit), Hacettepe University, Faculty of Medicine. **Specialist in Department of Pathology , Hacettepe University, Faculty of Medicine. Mailing address: Ilhan Pasaoglu, M.D., Associate Professor, Department of Thoracic and Cardiovascular Surgery, Hacettepe University, Faculty of Medicine, 06100 Hacettepe, Ankara, Turkey. Received for publication May 28, 1990. Accepted July 20, 1990. 147
148
PASAOGLU, ET AL.
Fig. 1. cle; LA=left
Fig.
Echocardiographic atrium; MV=mitral
2.
Operative
view
Jpn. Heart J. January 1991
appearance of the cyst. valve; cyst (arrows).
of the cyst
through
left
RV=
right ventri-
atriotomy
to Hacettepe University Medical Center because of a grade 2/6 short systolic ejection murmur at the apex and at the left sternal border. At admission he was a well developed, well nourished and anxious white man. Heart rate was 80/min, and the systemic blood pressure was 110/60mmHg. Physical examination was negative except for the heart. There was a grade 2/6 systolic ejection murmur at the apex with an ejection click, but no extension into the axilla. The same murmur was also heard at the upper left sternal border with an ejection click; no transmission was observed into the neck. The hemoglobin was 15.3g/dl, hematocrit 48%, and white blood count 7400/mm3. The electrocardiogram was found to be within normal limits. Postero-anterior telecardiogram revealed nothing abnormal and no evidence
Vol.32 No.1
GIANT BLOOD CYST OF THE LEFT VENTRICLE
Fig.
3.
chorda;
Postoperative
LV=left
echocardiography.
ventricle;
S= interventricular
RA=right
atrium;
septum;
PM=papillary
149
C=
muscle.
of
cardiac
chamber
enlargement.
Two-dimensional unilocular, left
echocardiography
ball-like
ventricle.
appeared
to
(Fig.
1).
be
to On
nulation
the
protection
elevated,
it and
leaflet.
It
cystic
mass,
opened, not
be
has
been
seen was
was
revealed
3.5cm
3).
valve
a
(Fig.
flowed
the
papillary
patient's
the
18th
the
2).
During
out.
The
muscle.
Since
postoperative day,
after
subvalvular
course
appeared
the
that
anterior unilocular
the the
cyst cyst
no
the quite
was could
murmur
uneventful
two-dimensional
revealed apparatus
of
was
papillary
of
operation was
opened,
leaflet
excision,
the
follow-up
was
outlined,
layer
can-
myocardial
anterior
margin
the
basillar
sterno-
mitral
the
free
at-
separate
atrium
smoothly
Echocardiography and
from to
with
median
and
anterior
originated
circumscribed,
diameter
The
echocardiography.
cyst
a with
left
tendinae
recommended.
(28•Ž), The
the and
valve
through
the
within
mitral
technique
After
attachment
fluid
from
pler
mitral
as
in
on
the
a minimal
bloody
heard.
seen.
round,
contraction
was
hypothermia
a
chordae
the
performed
was
diameter
and/or of
intervention
cardioplegia. was
that
in cardiac
cyst
bypass
moderate
mass
was
discharged
was
chrystalloid
cystic
was
cavity,
cava,
cold
removed
Surgical
there
with
muscle
a simple
surgery
that
3.5cm down
papillary was
1990
there
and
the
and
cardiopulmonary vena
red
up
muscle.
7,
each
dark
muscle
to
papillary
with
a
approximately
moved
diagnosis
standard of
and
final
February
with
mass
cyst
attached
The
tachment
tomy
cystic
The
revealed
and and
left
he Dop-
ventricular normal
(Fig.
150
PASAOGLU, ET AL.
Fig. elements.
4.
Microscopic
section
of
the
cystic
wall
Jpn. Heart J. January 1991
composed
of fibrocollagen
H.E.•~60.
Pathologic examination of the cyst: The wall of the cyst was 0.1-0.2cm in thickness, and lined with a single layer of flattened cells showing no definite epithelial, endothelial or pericardial character. Microscopic sections of the cystic wall revealed fibrocollagen elements with a few lymphocytes (Fig. 4). DISCUSSION Blood cysts of the cardiac valves are quite rare in adults but are seen in small infants under 6 months of age.3)-6) They are usually found as small, rounded, multiple nodules varying from pinpoint to pinhead on the atrial surface of the atrioventricular valves, but are also seen less commonly on the ventricular surfaces of the semilunar valves.3),6) The cysts are usually sessile, but may be pedunculated. The incidence of these cysts ranges from 565) to 784)%. They are usually unilocular, but sometimes the cysts may be loculated. Frequently, the walls of the cysts are lined by a single layer of flattened endothelium. A single, large-sized valvular cyst in older children and adults has been infrequently reported in the literature. Blood-filled cysts of the pulmonary valves which were removed surgically have been reported by Liese et al,7) Cumming and Ferguson8) and Sakakibara et al.9) The only case report concerning symptomatic giant blood cysts, removed from the tricuspid valve in a 4-month-old infant was reported by Galluci et al.10) However, there was only one diagnosed and surgically treated blood cyst of the mitral valve that was reported by Leatherman et al.11) Despite a search of the literature
Vol.32 No.1
GIANT BLOOD CYST OF THE LEFT VENTRICLE
no other mitral
report
valve
explanations
According
crevices cause
cyst
have
to Boyd's
in the
with
the valve
tissue
is notably
of the
mode
of origin
cyst
originated
case,
the
filled
with
bloody
fluid.
been
theory,
cusp
theories
originating
from
the
papillary
muscle
of the
was found.
Several cysts.
of a blood
151
given
blood
subsequent
regarding
cysts
sealing
from
the
This
finding
some cysts
anterior
of choice
a matter
whenever
diagnosed.
previous symptoms disappeared tically following surgical removal
As
authors
blood
blood of fact
and the clinical of the cysts.
cysts in
course
Boyd's is the
all
enters
In
our
and
was
patho-
treatment
reported
improved
Be-
vascular
muscle
to support
blood
entry.3)
considered
papillary
was sufficient of valvular
the
portal
of
to be untenable.9),12)
mitral
genetic theory mentioned above. In conclusion, surgical removal
origin
when
off of the
avascular,12) of blood
occur
the
cases, drama-
REFERENCES 1. Elsasser C: Bericht uber die Ereignisse in der Gebaranstalt des Catherinen-Hospital im Jahre 1844. Med Correspondenzblatt 14: 297, 1844 2. Luschka H: Die Blutergusse im Gewebe der Herzklappen. Virchows Arch Path Anat 11: 144, 1857 3. Boyd TAB: Blood cysts on the heart valves of infants. Am J Pathol 25: 757, 1949 4. Levinson SA, Learner A: Blood cysts on the heart valves of newborn infants. Arch Pathol 14: 810, 1932 5. Begg JG: Blood-filled cysts in the cardiac cusps in foetal life and infants. J Path Bact 87: 177, 1964 6. Dow DR, Harper WF: Blood cysts in human cardiac valves. J Anat 71: 117, 1936 7. Liese GJ, Brainward SC, Goto U: Giant blood cysts of the pulmonary valve. New Engl J Med 269: 465, 1963 8. Cumming GR, Ferguson CC: An elusive tumor of the pulmonary valve associated with a coronary arteriovenous fistula. J Thorac Cardiovasc Surg 50: 715, 1965 9. Sakakibara S, Katsuhara K, Iida Y, Nishida H: Pulmonary subvalvular tumor. Dis Chest 51: 637, 1967 10. Galluci V, Stritoni P, Fasoli G, Thiene G: Giant blood cyst of tricuspid valve: Successful excision in an infant. Br Heart J 38: 990, 1976 11. Leatherman L, Leachman RD, Hallman GL, Cooley DA: Cyst of the mitral valve. Am J Cardiol 21: 428, 1968 12. Harper WF: The structure of the heart valves with special reference to their blood supply and the genesis of endocarditis. J Path Bact 57: 229, 1945
Blood
Cyst
PASAOGLU, M.D.,
of
Riza
the
Left
Ventricle
DOGAN, M.D.,
Filiz OZYILMAZ, M.D.,**
Aysel
and A. Yuksel
ORAM, M.D.,*
BOZER, M.D.
SUMMARY A case of a giant blood cyst within the left ventricle of a 34-year-old man is presented with a brief review of the literature and a discussion of the pathogenesis. Additional Blood cyst
B
LOOD ser
Indexing Words: Mitral valve
cysts in
on the
l844,1)
heart
and
valves
were
subsequently
observers
quent single
necropsy findings in infants under blood cyst, large enough to produce In
cyst
has been the
was
stressed
infrequently
following
case,
successfully
that
small
from
in
of the
time
1857.2)
cardiac
by Elsas-
Since valves
then
are
fre-
6 months of age.3)-5) However a clinical symptoms in older children in the literature.
a 34-year-old
removed
for the first
Luschka
cysts
reported
circulation
reported
by
many
or adults
have
Extracorporeal
the
male
patient
anterior
mitral
whose
giant
papillary
blood
muscle
is
presented.
CASE REPORT A 34-year-old of Medicine tient's
on
main
epigastric
man
was
February
5,
complaints area
For
2 months
He
was
had
been
treated told
relieved he had with
were
admitted
a beta
by his physician
The
gnawing,
by food noted
to the
1990. but
dyspnea
aching, recurring on exertion
receptor that
Hacettepe
past
blocker
it would
University,
history
revealed
soreness
and
an
or so after
hour and
and
be better
for him
the
burning
paroxysmal antacid.
Faculty
that
pa-
in the a meal.
coughing. However,
he
to be admitted
From the Department of Thoracic and Cardiovascular Surgery, Hacettepe University, Faculty of Medicine, Hacettepe, Ankara, Turkey. *Professor , Department of Internal Medicine (Cardiology Unit), Hacettepe University, Faculty of Medicine. **Specialist in Department of Pathology , Hacettepe University, Faculty of Medicine. Mailing address: Ilhan Pasaoglu, M.D., Associate Professor, Department of Thoracic and Cardiovascular Surgery, Hacettepe University, Faculty of Medicine, 06100 Hacettepe, Ankara, Turkey. Received for publication May 28, 1990. Accepted July 20, 1990. 147
148
PASAOGLU, ET AL.
Fig. 1. cle; LA=left
Fig.
Echocardiographic atrium; MV=mitral
2.
Operative
view
Jpn. Heart J. January 1991
appearance of the cyst. valve; cyst (arrows).
of the cyst
through
left
RV=
right ventri-
atriotomy
to Hacettepe University Medical Center because of a grade 2/6 short systolic ejection murmur at the apex and at the left sternal border. At admission he was a well developed, well nourished and anxious white man. Heart rate was 80/min, and the systemic blood pressure was 110/60mmHg. Physical examination was negative except for the heart. There was a grade 2/6 systolic ejection murmur at the apex with an ejection click, but no extension into the axilla. The same murmur was also heard at the upper left sternal border with an ejection click; no transmission was observed into the neck. The hemoglobin was 15.3g/dl, hematocrit 48%, and white blood count 7400/mm3. The electrocardiogram was found to be within normal limits. Postero-anterior telecardiogram revealed nothing abnormal and no evidence
Vol.32 No.1
GIANT BLOOD CYST OF THE LEFT VENTRICLE
Fig.
3.
chorda;
Postoperative
LV=left
echocardiography.
ventricle;
S= interventricular
RA=right
atrium;
septum;
PM=papillary
149
C=
muscle.
of
cardiac
chamber
enlargement.
Two-dimensional unilocular, left
echocardiography
ball-like
ventricle.
appeared
to
(Fig.
1).
be
to On
nulation
the
protection
elevated,
it and
leaflet.
It
cystic
mass,
opened, not
be
has
been
seen was
was
revealed
3.5cm
3).
valve
a
(Fig.
flowed
the
papillary
patient's
the
18th
the
2).
During
out.
The
muscle.
Since
postoperative day,
after
subvalvular
course
appeared
the
that
anterior unilocular
the the
cyst cyst
no
the quite
was could
murmur
uneventful
two-dimensional
revealed apparatus
of
was
papillary
of
operation was
opened,
leaflet
excision,
the
follow-up
was
outlined,
layer
can-
myocardial
anterior
margin
the
basillar
sterno-
mitral
the
free
at-
separate
atrium
smoothly
Echocardiography and
from to
with
median
and
anterior
originated
circumscribed,
diameter
The
echocardiography.
cyst
a with
left
tendinae
recommended.
(28•Ž), The
the and
valve
through
the
within
mitral
technique
After
attachment
fluid
from
pler
mitral
as
in
on
the
a minimal
bloody
heard.
seen.
round,
contraction
was
hypothermia
a
chordae
the
performed
was
diameter
and/or of
intervention
cardioplegia. was
that
in cardiac
cyst
bypass
moderate
mass
was
discharged
was
chrystalloid
cystic
was
cavity,
cava,
cold
removed
Surgical
there
with
muscle
a simple
surgery
that
3.5cm down
papillary was
1990
there
and
the
and
cardiopulmonary vena
red
up
muscle.
7,
each
dark
muscle
to
papillary
with
a
approximately
moved
diagnosis
standard of
and
final
February
with
mass
cyst
attached
The
tachment
tomy
cystic
The
revealed
and and
left
he Dop-
ventricular normal
(Fig.
150
PASAOGLU, ET AL.
Fig. elements.
4.
Microscopic
section
of
the
cystic
wall
Jpn. Heart J. January 1991
composed
of fibrocollagen
H.E.•~60.
Pathologic examination of the cyst: The wall of the cyst was 0.1-0.2cm in thickness, and lined with a single layer of flattened cells showing no definite epithelial, endothelial or pericardial character. Microscopic sections of the cystic wall revealed fibrocollagen elements with a few lymphocytes (Fig. 4). DISCUSSION Blood cysts of the cardiac valves are quite rare in adults but are seen in small infants under 6 months of age.3)-6) They are usually found as small, rounded, multiple nodules varying from pinpoint to pinhead on the atrial surface of the atrioventricular valves, but are also seen less commonly on the ventricular surfaces of the semilunar valves.3),6) The cysts are usually sessile, but may be pedunculated. The incidence of these cysts ranges from 565) to 784)%. They are usually unilocular, but sometimes the cysts may be loculated. Frequently, the walls of the cysts are lined by a single layer of flattened endothelium. A single, large-sized valvular cyst in older children and adults has been infrequently reported in the literature. Blood-filled cysts of the pulmonary valves which were removed surgically have been reported by Liese et al,7) Cumming and Ferguson8) and Sakakibara et al.9) The only case report concerning symptomatic giant blood cysts, removed from the tricuspid valve in a 4-month-old infant was reported by Galluci et al.10) However, there was only one diagnosed and surgically treated blood cyst of the mitral valve that was reported by Leatherman et al.11) Despite a search of the literature
Vol.32 No.1
GIANT BLOOD CYST OF THE LEFT VENTRICLE
no other mitral
report
valve
explanations
According
crevices cause
cyst
have
to Boyd's
in the
with
the valve
tissue
is notably
of the
mode
of origin
cyst
originated
case,
the
filled
with
bloody
fluid.
been
theory,
cusp
theories
originating
from
the
papillary
muscle
of the
was found.
Several cysts.
of a blood
151
given
blood
subsequent
regarding
cysts
sealing
from
the
This
finding
some cysts
anterior
of choice
a matter
whenever
diagnosed.
previous symptoms disappeared tically following surgical removal
As
authors
blood
blood of fact
and the clinical of the cysts.
cysts in
course
Boyd's is the
all
enters
In
our
and
was
patho-
treatment
reported
improved
Be-
vascular
muscle
to support
blood
entry.3)
considered
papillary
was sufficient of valvular
the
portal
of
to be untenable.9),12)
mitral
genetic theory mentioned above. In conclusion, surgical removal
origin
when
off of the
avascular,12) of blood
occur
the
cases, drama-
REFERENCES 1. Elsasser C: Bericht uber die Ereignisse in der Gebaranstalt des Catherinen-Hospital im Jahre 1844. Med Correspondenzblatt 14: 297, 1844 2. Luschka H: Die Blutergusse im Gewebe der Herzklappen. Virchows Arch Path Anat 11: 144, 1857 3. Boyd TAB: Blood cysts on the heart valves of infants. Am J Pathol 25: 757, 1949 4. Levinson SA, Learner A: Blood cysts on the heart valves of newborn infants. Arch Pathol 14: 810, 1932 5. Begg JG: Blood-filled cysts in the cardiac cusps in foetal life and infants. J Path Bact 87: 177, 1964 6. Dow DR, Harper WF: Blood cysts in human cardiac valves. J Anat 71: 117, 1936 7. Liese GJ, Brainward SC, Goto U: Giant blood cysts of the pulmonary valve. New Engl J Med 269: 465, 1963 8. Cumming GR, Ferguson CC: An elusive tumor of the pulmonary valve associated with a coronary arteriovenous fistula. J Thorac Cardiovasc Surg 50: 715, 1965 9. Sakakibara S, Katsuhara K, Iida Y, Nishida H: Pulmonary subvalvular tumor. Dis Chest 51: 637, 1967 10. Galluci V, Stritoni P, Fasoli G, Thiene G: Giant blood cyst of tricuspid valve: Successful excision in an infant. Br Heart J 38: 990, 1976 11. Leatherman L, Leachman RD, Hallman GL, Cooley DA: Cyst of the mitral valve. Am J Cardiol 21: 428, 1968 12. Harper WF: The structure of the heart valves with special reference to their blood supply and the genesis of endocarditis. J Path Bact 57: 229, 1945
