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Repair of left ventricular diverticulum with ventricular bigeminy in an infant
Ann Thorac Surg 1998;66:1421–3
to beat and the anesthetist could ventilate the lung with oxygen. Within a short time cyanosis disappeared, but to get an acceptable blood pressure the circulation had to be supported with epinephrine. The chest was drained and closed. The elapsed time between cardiac arrest in the ward and the restoration of circulation was estimated to be 4 minutes. Because of insufficient respiration the patient was ventilated for a few days, and the circulation was supported with decreasing amounts of epinephrine. Pulmonary scintigraphy on the first postoperative day demonstrated a slightly diminished circulation in the posterior parts of the lower lobes (with the patient in a recumbent position). The patient recovered rapidly and left the hospital on the 21st day without signs of cerebral damage. This patient is now 86 years old, mentally normal, living alone, and doing her own housekeeping. She remembers the hospital stay and the past years as worth living.
CASE REPORT KAWATA ET AL LEFT VENTRICULAR DIVERTICULUM IN AN INFANT
1421
A 2,882-g male infant was born with a diagnosis of fetal arrhythmia and left ventricular diverticulum, which had been detected at 36 weeks’ gestation by prenatal ultrasound scanning. Congestive heart failure with symptoms such as vomiting, oligonuria, cardiomegaly, and systemic edema were controlled with conservative therapies such as diuretics. However, ventricular bigeminy with monofocal premature ventricular contractions (PVCs), which had begun on his second day of life, increased its frequency. The bigeminy recovered to sinus rhythm spontaneously in a few minutes, but occurred several times an hour even during a rest period such as sleeping. No cardiac murmur was heard. The liver was palpable 1 cm
Repair of Left Ventricular Diverticulum With Ventricular Bigeminy in an Infant Hiroaki Kawata, MD, Hidefumi Kishimoto, MD, Takayoshi Ueno, MD, Futoshi Kayatani, MD, and Tohru Mori, MD Departments of Cardiovascular Surgery and Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
Surgical repair of left ventricular diverticulum usually is not required in infancy even though it combines with other anomalies. In addition to prevention of rupture of the diverticulum and thrombus formation, treatment of combined ventricular tachycardia is thought to be an indication for resection of the diverticulum. We describe a successful repair performed by excising the isolated left ventricular diverticulum under cardiopulmonary bypass in a 9-day-old infant. The combined ventricular bigeminy has disappeared 9 months after the operation. (Ann Thorac Surg 1998;66:1421–3) © 1998 by The Society of Thoracic Surgeons
I
solated left ventricular diverticulum is a rare and usually asymptomatic cardiac malformation. Surgical treatment of this anomaly usually is not required during infancy even though the diverticulum is associated with other congenital anomalies such as midline thoracoabdominal defects and other cardiac anomalies. Under cardiopulmonary bypass, we resected the left ventricular diverticulum of a 9-day-old boy who had suffered from ventricular bigeminy.
Accepted for publication April 28, 1998. Address reprint requests to Dr Kawata, Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodocho, Izumi City, Osaka 594-1101, Japan.
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Frontal view of left ventriculogram at end-diastolic (A) and end-systolic phase (B). End-diastolic volume index of the true left ventricle excluding the left ventricular diverticulum at the apex was estimated as 40 mL/m2 (79% of normal left ventricle). The connection to the left ventricular cavity was narrow. (Diverticulum 5 left ventricular diverticulum; LV 5 true left ventricle.) 0003-4975/98/$19.00 PII S0003-4975(98)00789-9
1422
CASE REPORT KAWATA ET AL LEFT VENTRICULAR DIVERTICULUM IN AN INFANT
Ann Thorac Surg 1998;66:1421–3
Fig 2. Electrocardiogram during ventricular bigeminy; the focus of the monofocal premature ventricular contractions was thought to be located at the posteroinferior wall of the ventricle.
at his subcostal space. There were no other associated malformations such as midline thoracic, diaphragmatic, or abdominal wall defects. Ultrasonic echocardiography suggested a left ventricular diverticulum at the apex with a diameter of 20 mm. The posterior wall looked thin and fibrous. There was no thrombus detected in the diverticulum. Mitral valve regurgitation was not detected. No other intracardiac abnormalities were shown except a patent foramen ovale. A left ventricular cineangiogram also showed a large diverticulum at the apex with a narrow connection to the left ventricular cavity. The end-diastolic volume index of the left ventricle including and excluding the diverticulum were estimated as 73.5 mL/m2 (145% of normal left ventricle) and 40 mL/m2 (79%), respectively (Fig 1). The ejection fraction of the whole left ventricle and the true left ventricle excluding the diverticulum were 0.37 and 0.51, respectively. The diverticulum contracted synchronously with the true left ventricle but hypokinetically at the thin-walled posterior wall. There were no anomalies of coronary arteries. The electrocardiogram showed bigeminy with monofocal PVCs, which were thought to originate from the posteroinferior wall of the ventricle (Fig 2). The patient underwent surgical removal of this muscular-type diverticulum at 9 days of life as a treatment to control the arrythmia and to prevent rupture and thrombus formation. The diverticulum was located at the left ventricular apex with a narrow connection to the true left ventricle. The diameter was 20 mm. It was excised under cardiopulmonary bypass and cardioplegic arrest. The edge was doubly closed with a 5-0 monofilament by continuous mattress and over-and-over running suture. No thrombus was seen in the diverticulum. The posterior wall was as thin as 1 mm. Histologic examination revealed complete structure of the ventricle with three layers of endocardium, myocardium, and epicardium. However, much fibrous tissue was detected in the muscular layer. His postoperative course was uneventful and
he was doing well 9 months after the operation. No PVCs occurred after the operation.
Comment Although it is difficult to diagnose isolated left ventricular diverticulum because of its asymptomaticity, recent advances in diagnostic methods such as ultrasonic echocardiography make it possible even in neonates and fetuses [1], as in this case. The reported frequency of the diverticulum was 0.4% in autopsies of hearts with congenital cardiac defects [2] and 0.45% in one series of 2,000 children undergoing routine cardiac catheterization [3]. The real incidence of left ventricular diverticulum may be even greater [2– 4]. However, early detection of this defect may not be helpful for early treatment, because surgical treatment is not necessary in infancy in many cases depending on the symptoms. In contrast, some authors have insisted on surgical treatment to prevent rupture and thrombus formation even in asymptomatic cases [4]. The left ventricular diverticulum is usually treated concurrently with surgical treatment for other combined anomalies such as midline thoracoabdominal defects and other cardiac anomalies. Only a few cases have been treated during infancy [5] and the diverticulum in most of those cases was combined with other anomalies. The main indication for surgical treatment in our patient was management of PVCs, and the PVCs disappeared after the resection of the diverticulum. Some reports have described successful ventricular aneurysmectomy to treat ventricular tachycardia combined with ventricular diverticulum [3, 6]; in those reports the operation was performed in adult patients [6], for right ventricular diverticulum [3], and not for PVCs but for ventricular tachycardia. Frequent PVCs combined with cardiac failure may be an indication for surgical treatment of left ventricular diverticulum in early infancy.
Ann Thorac Surg 1998;66:1423– 4
CASE REPORT NOMORI ET AL LYMPHOMA OF SUPERIOR VENA CAVA
1423
References 1. Kitchiner D, Leung MP, Arnold R. Isolated congenital left ventricular diverticulum: echocardiographic features in a fetus. Am Heart J 1990;119:1435–7. 2. Pressoir R, Downing JW. Congenital diverticula of the right ventricle of the heart: a case report. J Natl Med Assoc 1980;72: 262– 4. 3. Hamaoka K, Onaka M, Tanaka T, Onouchi Z. Congenital ventricular aneurysm and diverticulum in children. Pediatr Cardiol 1987;8:169–75. 4. Okereke OUJ, Cooley DA, Frazier OH. Congenital diverticulum of the ventricle. J Thorac Cardiovasc Surg 1986;91:208–14. 5. Ushida N, Ohsawa M, Toyoizumi M, et al. Diverticulum of the left ventricle of the heart. Review of the literature and report of a successful removal of the diverticulum. Shinzo 1969;3: 331– 42. 6. Shen EN, Fukuyama O, Herre JM, Yee E, Scheinman MM. Ventricular tachycardia with congenital ventricular diverticulum. Chest 1991;100:283–5.
Primary Malignant Lymphoma of Superior Vena Cava Hiroaki Nomori, MD, Sadahiro Nara, MD, Shojiroh Morinaga, MD, and Kyoko Soejima, MD Departments of Surgery and Pathology, Saiseikai Central Hospital, and Department of Medicine, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
A 78-year-old woman suffered from superior vena cava (SVC) syndrome. Computed tomography and angiography revealed a mass within the SVC. The SVC was resected via median sternotomy, followed by reconstruction using an artificial graft. The resected specimen showed a polypoid tumor within the SVC that had invaded the wall of the SVC. Histologic diagnosis was diffuse large-cell non-Hodgkin’s lymphoma. Most surrounding lymph nodes showed reactive swelling, but one showed a partial microscopic metastasis. These pathologic findings indicated that the tumor was an SVC-originating malignant lymphoma. The patient is now alive and tumor-free 65 months after the operation. (Ann Thorac Surg 1998;66:1423– 4) © 1998 by The Society of Thoracic Surgeons
Fig 1. Chest computed tomogram showing an expanded superior vena cava with an intraluminal mass (arrow) and enlarged paratracheal lymph node.
central to a peripheral site with a low-density intraluminal mass, and paratracheal lymph nodes to be swollen (Fig 1). A contrast superior vena cavogram showed an obstructed SVC and numerous collateral vessels (Fig 2). Because of immediate worsening of the patient’s condition, an expandable metallic stent was introduced to treat SVC obstruction. Transvenous biopsy of the tumor revealed malignancy, but no further diagnosis could be made because of the occurrence of compressive artifacts. Systemic examination revealed no other tumors. An operation was conducted on May 7, 1992, via median sternotomy with right fourth intercostal thoracotomy. The SVC was enlarged to 4 cm in diameter, but no invasion of adjacent organs was seen. The bilateral brachiocephalic veins, azygos vein, and SVC including part of the right atrium were resected, and reconstruction was implemented with a ringed, expanded polytetrafluoroethylene graft 14 mm in diameter and 10 cm long
S
uperior vena cava (SVC) syndrome due to malignant lymphoma is usually caused by SVC obstruction after a tumor from a primary anterior mediastinal lesion has spread. We present a case of SVC-originating malignant lymphoma treated by operation followed by chemotherapy. A 78-year-old woman complained of facial and bilateral arm swelling in March 1992, and was admitted to Saiseikai Central Hospital on April 28, 1992. Chest computed tomography showed the SVC to have expanded from a
Accepted for publication April 11, 1998. Address reprint requests to Dr Nomori, Department of Surgery, Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108-0073, Japan.
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 2. Contrast superior vena cavogram showing obstructed superior vena cava and collateral veins. 0003-4975/98/$19.00 PII S0003-4975(98)00641-9
to beat and the anesthetist could ventilate the lung with oxygen. Within a short time cyanosis disappeared, but to get an acceptable blood pressure the circulation had to be supported with epinephrine. The chest was drained and closed. The elapsed time between cardiac arrest in the ward and the restoration of circulation was estimated to be 4 minutes. Because of insufficient respiration the patient was ventilated for a few days, and the circulation was supported with decreasing amounts of epinephrine. Pulmonary scintigraphy on the first postoperative day demonstrated a slightly diminished circulation in the posterior parts of the lower lobes (with the patient in a recumbent position). The patient recovered rapidly and left the hospital on the 21st day without signs of cerebral damage. This patient is now 86 years old, mentally normal, living alone, and doing her own housekeeping. She remembers the hospital stay and the past years as worth living.
CASE REPORT KAWATA ET AL LEFT VENTRICULAR DIVERTICULUM IN AN INFANT
1421
A 2,882-g male infant was born with a diagnosis of fetal arrhythmia and left ventricular diverticulum, which had been detected at 36 weeks’ gestation by prenatal ultrasound scanning. Congestive heart failure with symptoms such as vomiting, oligonuria, cardiomegaly, and systemic edema were controlled with conservative therapies such as diuretics. However, ventricular bigeminy with monofocal premature ventricular contractions (PVCs), which had begun on his second day of life, increased its frequency. The bigeminy recovered to sinus rhythm spontaneously in a few minutes, but occurred several times an hour even during a rest period such as sleeping. No cardiac murmur was heard. The liver was palpable 1 cm
Repair of Left Ventricular Diverticulum With Ventricular Bigeminy in an Infant Hiroaki Kawata, MD, Hidefumi Kishimoto, MD, Takayoshi Ueno, MD, Futoshi Kayatani, MD, and Tohru Mori, MD Departments of Cardiovascular Surgery and Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
Surgical repair of left ventricular diverticulum usually is not required in infancy even though it combines with other anomalies. In addition to prevention of rupture of the diverticulum and thrombus formation, treatment of combined ventricular tachycardia is thought to be an indication for resection of the diverticulum. We describe a successful repair performed by excising the isolated left ventricular diverticulum under cardiopulmonary bypass in a 9-day-old infant. The combined ventricular bigeminy has disappeared 9 months after the operation. (Ann Thorac Surg 1998;66:1421–3) © 1998 by The Society of Thoracic Surgeons
I
solated left ventricular diverticulum is a rare and usually asymptomatic cardiac malformation. Surgical treatment of this anomaly usually is not required during infancy even though the diverticulum is associated with other congenital anomalies such as midline thoracoabdominal defects and other cardiac anomalies. Under cardiopulmonary bypass, we resected the left ventricular diverticulum of a 9-day-old boy who had suffered from ventricular bigeminy.
Accepted for publication April 28, 1998. Address reprint requests to Dr Kawata, Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodocho, Izumi City, Osaka 594-1101, Japan.
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Frontal view of left ventriculogram at end-diastolic (A) and end-systolic phase (B). End-diastolic volume index of the true left ventricle excluding the left ventricular diverticulum at the apex was estimated as 40 mL/m2 (79% of normal left ventricle). The connection to the left ventricular cavity was narrow. (Diverticulum 5 left ventricular diverticulum; LV 5 true left ventricle.) 0003-4975/98/$19.00 PII S0003-4975(98)00789-9
1422
CASE REPORT KAWATA ET AL LEFT VENTRICULAR DIVERTICULUM IN AN INFANT
Ann Thorac Surg 1998;66:1421–3
Fig 2. Electrocardiogram during ventricular bigeminy; the focus of the monofocal premature ventricular contractions was thought to be located at the posteroinferior wall of the ventricle.
at his subcostal space. There were no other associated malformations such as midline thoracic, diaphragmatic, or abdominal wall defects. Ultrasonic echocardiography suggested a left ventricular diverticulum at the apex with a diameter of 20 mm. The posterior wall looked thin and fibrous. There was no thrombus detected in the diverticulum. Mitral valve regurgitation was not detected. No other intracardiac abnormalities were shown except a patent foramen ovale. A left ventricular cineangiogram also showed a large diverticulum at the apex with a narrow connection to the left ventricular cavity. The end-diastolic volume index of the left ventricle including and excluding the diverticulum were estimated as 73.5 mL/m2 (145% of normal left ventricle) and 40 mL/m2 (79%), respectively (Fig 1). The ejection fraction of the whole left ventricle and the true left ventricle excluding the diverticulum were 0.37 and 0.51, respectively. The diverticulum contracted synchronously with the true left ventricle but hypokinetically at the thin-walled posterior wall. There were no anomalies of coronary arteries. The electrocardiogram showed bigeminy with monofocal PVCs, which were thought to originate from the posteroinferior wall of the ventricle (Fig 2). The patient underwent surgical removal of this muscular-type diverticulum at 9 days of life as a treatment to control the arrythmia and to prevent rupture and thrombus formation. The diverticulum was located at the left ventricular apex with a narrow connection to the true left ventricle. The diameter was 20 mm. It was excised under cardiopulmonary bypass and cardioplegic arrest. The edge was doubly closed with a 5-0 monofilament by continuous mattress and over-and-over running suture. No thrombus was seen in the diverticulum. The posterior wall was as thin as 1 mm. Histologic examination revealed complete structure of the ventricle with three layers of endocardium, myocardium, and epicardium. However, much fibrous tissue was detected in the muscular layer. His postoperative course was uneventful and
he was doing well 9 months after the operation. No PVCs occurred after the operation.
Comment Although it is difficult to diagnose isolated left ventricular diverticulum because of its asymptomaticity, recent advances in diagnostic methods such as ultrasonic echocardiography make it possible even in neonates and fetuses [1], as in this case. The reported frequency of the diverticulum was 0.4% in autopsies of hearts with congenital cardiac defects [2] and 0.45% in one series of 2,000 children undergoing routine cardiac catheterization [3]. The real incidence of left ventricular diverticulum may be even greater [2– 4]. However, early detection of this defect may not be helpful for early treatment, because surgical treatment is not necessary in infancy in many cases depending on the symptoms. In contrast, some authors have insisted on surgical treatment to prevent rupture and thrombus formation even in asymptomatic cases [4]. The left ventricular diverticulum is usually treated concurrently with surgical treatment for other combined anomalies such as midline thoracoabdominal defects and other cardiac anomalies. Only a few cases have been treated during infancy [5] and the diverticulum in most of those cases was combined with other anomalies. The main indication for surgical treatment in our patient was management of PVCs, and the PVCs disappeared after the resection of the diverticulum. Some reports have described successful ventricular aneurysmectomy to treat ventricular tachycardia combined with ventricular diverticulum [3, 6]; in those reports the operation was performed in adult patients [6], for right ventricular diverticulum [3], and not for PVCs but for ventricular tachycardia. Frequent PVCs combined with cardiac failure may be an indication for surgical treatment of left ventricular diverticulum in early infancy.
Ann Thorac Surg 1998;66:1423– 4
CASE REPORT NOMORI ET AL LYMPHOMA OF SUPERIOR VENA CAVA
1423
References 1. Kitchiner D, Leung MP, Arnold R. Isolated congenital left ventricular diverticulum: echocardiographic features in a fetus. Am Heart J 1990;119:1435–7. 2. Pressoir R, Downing JW. Congenital diverticula of the right ventricle of the heart: a case report. J Natl Med Assoc 1980;72: 262– 4. 3. Hamaoka K, Onaka M, Tanaka T, Onouchi Z. Congenital ventricular aneurysm and diverticulum in children. Pediatr Cardiol 1987;8:169–75. 4. Okereke OUJ, Cooley DA, Frazier OH. Congenital diverticulum of the ventricle. J Thorac Cardiovasc Surg 1986;91:208–14. 5. Ushida N, Ohsawa M, Toyoizumi M, et al. Diverticulum of the left ventricle of the heart. Review of the literature and report of a successful removal of the diverticulum. Shinzo 1969;3: 331– 42. 6. Shen EN, Fukuyama O, Herre JM, Yee E, Scheinman MM. Ventricular tachycardia with congenital ventricular diverticulum. Chest 1991;100:283–5.
Primary Malignant Lymphoma of Superior Vena Cava Hiroaki Nomori, MD, Sadahiro Nara, MD, Shojiroh Morinaga, MD, and Kyoko Soejima, MD Departments of Surgery and Pathology, Saiseikai Central Hospital, and Department of Medicine, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
A 78-year-old woman suffered from superior vena cava (SVC) syndrome. Computed tomography and angiography revealed a mass within the SVC. The SVC was resected via median sternotomy, followed by reconstruction using an artificial graft. The resected specimen showed a polypoid tumor within the SVC that had invaded the wall of the SVC. Histologic diagnosis was diffuse large-cell non-Hodgkin’s lymphoma. Most surrounding lymph nodes showed reactive swelling, but one showed a partial microscopic metastasis. These pathologic findings indicated that the tumor was an SVC-originating malignant lymphoma. The patient is now alive and tumor-free 65 months after the operation. (Ann Thorac Surg 1998;66:1423– 4) © 1998 by The Society of Thoracic Surgeons
Fig 1. Chest computed tomogram showing an expanded superior vena cava with an intraluminal mass (arrow) and enlarged paratracheal lymph node.
central to a peripheral site with a low-density intraluminal mass, and paratracheal lymph nodes to be swollen (Fig 1). A contrast superior vena cavogram showed an obstructed SVC and numerous collateral vessels (Fig 2). Because of immediate worsening of the patient’s condition, an expandable metallic stent was introduced to treat SVC obstruction. Transvenous biopsy of the tumor revealed malignancy, but no further diagnosis could be made because of the occurrence of compressive artifacts. Systemic examination revealed no other tumors. An operation was conducted on May 7, 1992, via median sternotomy with right fourth intercostal thoracotomy. The SVC was enlarged to 4 cm in diameter, but no invasion of adjacent organs was seen. The bilateral brachiocephalic veins, azygos vein, and SVC including part of the right atrium were resected, and reconstruction was implemented with a ringed, expanded polytetrafluoroethylene graft 14 mm in diameter and 10 cm long
S
uperior vena cava (SVC) syndrome due to malignant lymphoma is usually caused by SVC obstruction after a tumor from a primary anterior mediastinal lesion has spread. We present a case of SVC-originating malignant lymphoma treated by operation followed by chemotherapy. A 78-year-old woman complained of facial and bilateral arm swelling in March 1992, and was admitted to Saiseikai Central Hospital on April 28, 1992. Chest computed tomography showed the SVC to have expanded from a
Accepted for publication April 11, 1998. Address reprint requests to Dr Nomori, Department of Surgery, Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108-0073, Japan.
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 2. Contrast superior vena cavogram showing obstructed superior vena cava and collateral veins. 0003-4975/98/$19.00 PII S0003-4975(98)00641-9