JCCT691_proof ■ 12 May 2014 ■ 1/2 J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y x x ( 2 0 1 4 ) 1 e2
Available online at www.sciencedirect.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
ScienceDirect journal homepage: www.JournalofCardiovascularCT.com
Images in Cardiovascular CT
Lipomatous hypertrophy presenting as superior vena cava syndrome Q1
Michael K. Cheezum MD*, Matthew R. Jezior MD, Salvatore Carbonaro MD, Todd C. Villines MD Cardiology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda MD 20889, USA
article info Q5 Article history:
Received 13 December 2013
abstract ---.
ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved.
Received in revised form 4 April 2014 Accepted 22 April 2014 Available online xxx Keywords: Computed tomography Cardiac CT Cardiac mass Lipoma Lipomatous hypertrophy Interatrial septum Superior vena cava SVC syndrome
Q2 An 84-year-old woman presented with headaches and pro-
gressive, lifestyle-limiting dyspnea on exertion over a 6-month period, provoked by minimal ambulation and tying her shoes. At rest she was in no distress with normal vital signs, mild jugular venous distention, and an otherwise normal examination. Electrocardiogram and chest roentgenogram were normal, and transthoracic echocardiography noted a right Q3 atrial mass that prompted transesophageal echocardiography.
The transesophageal echocardiography showed a 2.1 3.5-cm echobright mass that extended from the superior vena cava (SVC) into the superior right atrium (RA) (Fig. 1A), with normal biventricular function and no significant valvular disease. Electrocardiogram-gated, 64-slice cardiac CT showed normal lung findings and prominent brachiocephalic veins with a minimally enhancing 4-cm homogenous, low-attenuating fatty mass at the junction of the SVC and RA, involving the
Conflict of interest: The authors report no conflict of interest. The views expressed here are those of the authors only and are not to be construed as those of the Department of the Defense or the United States government. * Corresponding author. E-mail address: [email protected] (M.K. Cheezum). 1934-5925/$ e see front matter ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved. http://dx.doi.org/10.1016/j.jcct.2014.04.005
Please cite this article in press as: Cheezum MK, et al., Lipomatous hypertrophy presenting as superior vena cava syndrome, Journal of Cardiovascular Computed Tomography (2014), http://dx.doi.org/10.1016/j.jcct.2014.04.005
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
JCCT691_proof ■ 12 May 2014 ■ 2/2
2
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y x x ( 2 0 1 4 ) 1 e2
web 4C=FPO
131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 Fig. 1 e Lipomatous hypertrophy of the interatrial septum presenting as SVC syndrome. (A) Transesophageal 155 echocardiogram, bicaval view, shows echobright mass (arrows) that involves the interatrial septum and superior RA with 156 157 Q4 narrowing of the junction of the SVC and RA and relative sparing of the fossa ovalis (v). (B) Cardiac CT, 4-chamber view, 158 shows a low attenuation mass that involves the interatrial septum (arrows) and extends to the superior RA (*). (C) Cardiac 159 CT, sagittal view, shows a low attenuation mass with minimal enhancement (mean signal, L55 ± 12 HU), narrowing of the 160 SVC/RA junction (minimum diameter, 0.5 cm), and sparing of the fossa ovalis (v). Note that contrast administration was 161 affected by SVC obstruction, resulting in delayed and equal opacification of left and right heart structures on first-pass 162 imaging. (D) Fat-subtracted volume rendered cardiac CT shows narrowing at the SVC/RA junction (arrow). (E) Intraoperative 163 photo shows the lipomatous mass (arrow) encircling the superior RA. (F) Intraoperative photo shows the BPP applied to close 164 the large right atrial defect, resulting from the extensive resection required to achieve complete excision of the infiltrating 165 166 fatty mass. Epicardial pacer leads (not shown) were placed because of the resulting sinoatrial node resection. BPP, bovine 167 pericardial patch; IVC, inferior vena cava; LA, left atrium; RA, right atrium; SVC, superior vena cava. 168 169 170 171 arrhythmias, impaired venous return, and sudden cardiac interatrial septum with relative sparing of the fossa ovalis, and 172 death have been described.1 Findings consistent with liponarrowing of the SVC (Fig. 1BeD). Of note, stress myocardial 173 174 matous hypertrophy of the interatrial septum include a perfusion imaging was unremarkable, and the patient had a 175 dumbbell shape with sparing of the fossa ovalis, sharp marnormal chronotropic response to exercise. In addition, right 176 gins, and minimal contrast enhancement.2 In masses of unheart catheterization was performed and showed normal 177 clear etiology or rare cases that result in cavity obstruction, mean pulmonary artery and capillary wedge pressures, normal 178 cardiac CT provides complementary information to define oxygen saturation, and no evidence of an intracardiac shunt. 179 tumor extent and to characterize classic mass features, For suspected symptom-limiting SVC syndrome, surgery 180 facilitating diagnosis and management. was performed with extensive resection of the RA that 181 182 necessitated a bovine pericardial patch (Fig. 1EeF) and sub183 sequent dual-chamber pacemaker placement for new onset 184 references chronotropic incompetence. Pathology confirmed locally 185 advanced, benign lipomatous hypertrophy. At the 6-month 186 follow-up the patient reported early and marked improve187 1. Rojas CA, Jaimes CE, El-Sherief AH, et al. Cardiac CT of nonments from her baseline, ambulating several blocks with no 188 shunt pathology of the interatrial septum. J Cardiovasc Comput 189 exertional or positional symptoms. Tomogr. 2011;5:93e100. 190 Lipomatous hypertrophy of the interatrial septum has a 2. Heyer CM, Kagel T, Lemburg SP, Bauer TT, Nicolas V. 191 prevalence of 1% to 8% and typically occurs in elderly Lipomatous hypertrophy of the interatrial septum: a 192 and obese populations.1 Classically, it is an incidental finding prospective study of incidence, imaging findings, and clinical 193 symptoms. Chest. 2003;124:2068e2073. with a benign course, although associations with atrial 194
Please cite this article in press as: Cheezum MK, et al., Lipomatous hypertrophy presenting as superior vena cava syndrome, Journal of Cardiovascular Computed Tomography (2014), http://dx.doi.org/10.1016/j.jcct.2014.04.005
195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258
Available online at www.sciencedirect.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
ScienceDirect journal homepage: www.JournalofCardiovascularCT.com
Images in Cardiovascular CT
Lipomatous hypertrophy presenting as superior vena cava syndrome Q1
Michael K. Cheezum MD*, Matthew R. Jezior MD, Salvatore Carbonaro MD, Todd C. Villines MD Cardiology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda MD 20889, USA
article info Q5 Article history:
Received 13 December 2013
abstract ---.
ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved.
Received in revised form 4 April 2014 Accepted 22 April 2014 Available online xxx Keywords: Computed tomography Cardiac CT Cardiac mass Lipoma Lipomatous hypertrophy Interatrial septum Superior vena cava SVC syndrome
Q2 An 84-year-old woman presented with headaches and pro-
gressive, lifestyle-limiting dyspnea on exertion over a 6-month period, provoked by minimal ambulation and tying her shoes. At rest she was in no distress with normal vital signs, mild jugular venous distention, and an otherwise normal examination. Electrocardiogram and chest roentgenogram were normal, and transthoracic echocardiography noted a right Q3 atrial mass that prompted transesophageal echocardiography.
The transesophageal echocardiography showed a 2.1 3.5-cm echobright mass that extended from the superior vena cava (SVC) into the superior right atrium (RA) (Fig. 1A), with normal biventricular function and no significant valvular disease. Electrocardiogram-gated, 64-slice cardiac CT showed normal lung findings and prominent brachiocephalic veins with a minimally enhancing 4-cm homogenous, low-attenuating fatty mass at the junction of the SVC and RA, involving the
Conflict of interest: The authors report no conflict of interest. The views expressed here are those of the authors only and are not to be construed as those of the Department of the Defense or the United States government. * Corresponding author. E-mail address: [email protected] (M.K. Cheezum). 1934-5925/$ e see front matter ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved. http://dx.doi.org/10.1016/j.jcct.2014.04.005
Please cite this article in press as: Cheezum MK, et al., Lipomatous hypertrophy presenting as superior vena cava syndrome, Journal of Cardiovascular Computed Tomography (2014), http://dx.doi.org/10.1016/j.jcct.2014.04.005
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
JCCT691_proof ■ 12 May 2014 ■ 2/2
2
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y x x ( 2 0 1 4 ) 1 e2
web 4C=FPO
131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 Fig. 1 e Lipomatous hypertrophy of the interatrial septum presenting as SVC syndrome. (A) Transesophageal 155 echocardiogram, bicaval view, shows echobright mass (arrows) that involves the interatrial septum and superior RA with 156 157 Q4 narrowing of the junction of the SVC and RA and relative sparing of the fossa ovalis (v). (B) Cardiac CT, 4-chamber view, 158 shows a low attenuation mass that involves the interatrial septum (arrows) and extends to the superior RA (*). (C) Cardiac 159 CT, sagittal view, shows a low attenuation mass with minimal enhancement (mean signal, L55 ± 12 HU), narrowing of the 160 SVC/RA junction (minimum diameter, 0.5 cm), and sparing of the fossa ovalis (v). Note that contrast administration was 161 affected by SVC obstruction, resulting in delayed and equal opacification of left and right heart structures on first-pass 162 imaging. (D) Fat-subtracted volume rendered cardiac CT shows narrowing at the SVC/RA junction (arrow). (E) Intraoperative 163 photo shows the lipomatous mass (arrow) encircling the superior RA. (F) Intraoperative photo shows the BPP applied to close 164 the large right atrial defect, resulting from the extensive resection required to achieve complete excision of the infiltrating 165 166 fatty mass. Epicardial pacer leads (not shown) were placed because of the resulting sinoatrial node resection. BPP, bovine 167 pericardial patch; IVC, inferior vena cava; LA, left atrium; RA, right atrium; SVC, superior vena cava. 168 169 170 171 arrhythmias, impaired venous return, and sudden cardiac interatrial septum with relative sparing of the fossa ovalis, and 172 death have been described.1 Findings consistent with liponarrowing of the SVC (Fig. 1BeD). Of note, stress myocardial 173 174 matous hypertrophy of the interatrial septum include a perfusion imaging was unremarkable, and the patient had a 175 dumbbell shape with sparing of the fossa ovalis, sharp marnormal chronotropic response to exercise. In addition, right 176 gins, and minimal contrast enhancement.2 In masses of unheart catheterization was performed and showed normal 177 clear etiology or rare cases that result in cavity obstruction, mean pulmonary artery and capillary wedge pressures, normal 178 cardiac CT provides complementary information to define oxygen saturation, and no evidence of an intracardiac shunt. 179 tumor extent and to characterize classic mass features, For suspected symptom-limiting SVC syndrome, surgery 180 facilitating diagnosis and management. was performed with extensive resection of the RA that 181 182 necessitated a bovine pericardial patch (Fig. 1EeF) and sub183 sequent dual-chamber pacemaker placement for new onset 184 references chronotropic incompetence. Pathology confirmed locally 185 advanced, benign lipomatous hypertrophy. At the 6-month 186 follow-up the patient reported early and marked improve187 1. Rojas CA, Jaimes CE, El-Sherief AH, et al. Cardiac CT of nonments from her baseline, ambulating several blocks with no 188 shunt pathology of the interatrial septum. J Cardiovasc Comput 189 exertional or positional symptoms. Tomogr. 2011;5:93e100. 190 Lipomatous hypertrophy of the interatrial septum has a 2. Heyer CM, Kagel T, Lemburg SP, Bauer TT, Nicolas V. 191 prevalence of 1% to 8% and typically occurs in elderly Lipomatous hypertrophy of the interatrial septum: a 192 and obese populations.1 Classically, it is an incidental finding prospective study of incidence, imaging findings, and clinical 193 symptoms. Chest. 2003;124:2068e2073. with a benign course, although associations with atrial 194
Please cite this article in press as: Cheezum MK, et al., Lipomatous hypertrophy presenting as superior vena cava syndrome, Journal of Cardiovascular Computed Tomography (2014), http://dx.doi.org/10.1016/j.jcct.2014.04.005
195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258
