- Email: [email protected]
Ectopic thyroid tissue in the left ventricular outflow tract
620
CASE REPORT BAYKUT ET AL ECTOPIC THYROID - HEART
Ann Thorac Surg 2000;69:620 –1
3. Czer LSC, Trento A, Blanche C, et al. Orthotopic heart transplantation: clinical experience with a new technique. J Am Coll Cardiol 1993;21(Suppl A):168A. 4. Blanche C, Valenza M, Aleksic I, Czer LSC, Trento A. Technical considerations of a new technique for orthotopic heart transplantation. J Cardiovasc Surg 1994;35:283–7. 5. Duncan JM, Miodrag M, Frazier OH. Orthotopic cardiac transplantation in patients with large donor/recipient atrial size mismatch: surgical technique. Ann Thorac Surg 1987;44: 420–1.
Ectopic Thyroid Tissue in the Left Ventricular Outflow Tract Doan Baykut, MD, Udo Fiegen, MD, Arno Krian, MD, and Andreas Thiel, MD Clinic of Thoracic and Cardiovascular Surgery, Heart Center, Duisburg, Germany
Ectopic thyroid tissue in the heart (struma cordis) is rare. The only report from a hemodynamically significant obstruction of the left ventricular outflow tract (LVOT) by a heterotopic thyroid gland was published in 1988. In our patient, a 42-year-old woman with recurrent chest pain, two spheric cardiac tumors were diagnosed by transthoracal echocardiography. One of the tumors, obstructing the LVOT, could successfully be resected under cardiopulmonary bypass. The pathologic examination showed a colloid-filled ectopic thyroid gland. The second tumor, which was entirely located in the submembraneous part of the interventricular septum, had no hemodynamic influence, and was left in situ to avoid surgical damage of adjacent intraseptal structures. The midterm follow-up showed no recurrence. (Ann Thorac Surg 2000;69:620 –1) © 2000 by The Society of Thoracic Surgeons
Fig 1. Preoperative transesophageal echocardiographic image of the left ventricular outflow tract and interventricular septum. The first tumor is located directly under the aortic valve, while the second tumor is intraseptal, thinly covered by myocardium. (AV ⫽ aortic valve; IVS ⫽ interventricular septum; LV ⫽ left ventricle; LVOT ⫽ left ventricular outflow tract; TU ⫽ tumor).
valve leaflet, obstructing the LVOT. Ventriculography and coronary angiography showed an additional, similar sized tumor in the interventricular septum to the first one. Both tumors were perfused with coronary blood, mainly from the left coronary artery. By levography, a significant obstruction of the left ventricular cavity could not be verified. The motion of both aortic and mitral valves was not restricted. The left ventricular function and coronary status were normal. Laboratory findings were within normal values, including thyroid-related hormones. The ECG showed no remarkable changes. Since the characteristics of the tumors cannot be identified by a series of conservative methods, the exploratory
T
he heterotopic occurrence of the thyroid tissue in humans is mainly originated from embryological development abnormalities of the primitive heart [1–3]. The struma cordis, or ectopic thyroid gland, in the heart is an extremely rare finding [2, 4 – 6]. In the reported cases, the ectopic thyroid noduli were found predominantly in the right ventricular wall or interventricular septum [3, 4, 7]. In patients with an obstruction of intracardiac cavities, the right ventricular outflow tract (RVOT) was mainly involved [4, 9]. Kon and associates described an ectopic thyroid tissue in the left ventricular outflow tract (LVOT) in 1988 [5], which was successfully resected under cardiopulmonary bypass. A 42-year-old woman was admitted with recurrent retrosternal pain over a 4 to 5 week period. The cardiopulmonary history was unremarkable. By transthoracal echocardiography (ECG), a small homogenous tumor (1.25 ⫻ 1.0 ⫻ 1.0 cm) was revealed under the right coronary aortic Accepted for publication June 21, 1999. Address reprint requests to Dr Baykut, Clinic of Thoracic and Cardiovascular Surgery, Heart Center, Duisburg, D-47137 Duisburg, Germany.
© 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 2. Intraoperative situs. The left ventricular outflow tract is exposed through the aortic valve. The arrow marks the tumor partly obstructing the outflow tract. 0003-4975/99/$20.00 PII S0003-4975(00)01344-2
Ann Thorac Surg 2000;69:621–3
CASE REPORT ALCOCER ET AL ABERRANT RIGHT SUBCLAVIAN ARTERY
621
these cases can only be unveiled by a functional anomaly or malignant transformation. Since silent cardiac tumors can remain undetected over a lifetime, initial subjective symptoms like pain, angina, or dyspnea, often indicate an advanced stage of the disease caused by an obstruction of intracardiac cavities and vessels or valvular dysfunction. In these cases, the surgeon should be aware of managing the dilemma of a radical therapy with severe structural cardiac damage versus conservation of the cardiac function with the risk of an incomplete operation.
References Fig 3. Transesophageal echocardiographic image after tumor resection. The left ventricular outflow tract is now free of any obstruction. The primary tumor site appears slightly excavated (arrow). The second tumor, which was left in situ, is partly visible. (AO ⫽ aorta; LVOT ⫽ left ventricular outflow tract; NCC ⫽ noncoronary cusp of the aortic valve; RCC ⫽ right coronary cusp of the aortic valve.)
cardiotomy became necessary. The transesophageal echocardiography (TEE), which was carried out before the operation, displayed the tumors clearly in size and location (Fig 1). After opening the aortic root, the first tumor could be exposed in the LVOT under the right sinus of Valsalva (Fig 2). It was spherical, with a smooth capsular surface. A complete enucleation was possible without injury of the myocardial tissue. The specimen was urgently sent to the pathologic examination. The septally located second tumor could be exposed after opening the right atrium. By bidigital transtricuspid and transaortal palpation, the tumor was localized in the submembraneous ventricular septum. The entire tumor mass was intramural, well isolated and in direct contact with important anatomical structures (bundle of His, septal coronary branches, and left ventricular dorsal wall). Any attempt to remove this tissue, even incompletely, seemed hazardous to these structures, and would lead to a severe damage. Therefore, the operation was terminated without a further tumor resection. There were no intraoperative complications. In the following TEE, the LVOT was free of any obstruction, verifying the complete removal of the first tumor (Fig 3). The pathologic examination of the specimen showed a heterotopic thyroid tissue with colloid-filled follicles of different sizes and shapes. No signs of inflammatory disease or malignant growth were found. The postoperative clinical course was also without complication. After 9 days of clinical treatment, the patient was dismissed in good condition. At 1 year follow-up, she showed continuously good hemodynamical status without recurrence of the remaining intracardiac thyroid tissue.
Comment Tumors originating from a heterotopic extracardiac tissue are extremely rare, and there is no exact data about their percental distribution. In many cases, the heterotopy exists only in traces, leading to some coincidental findings in pathologic specimens. Heterotopic tissue in © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1. Kantelip B, Lusson JR, De Riberolles C, Lamaison D, Bailly P. Intracardiac ectopic thyroid. Hum Pathol 1986;17:1293– 6. 2. Kerlan V, Jobic Y, Boschat J, Barra JA, Penther P, Bercovici JP. Intracardiac ectopic thyroid. Ann Endocrinol (Paris) 1993;54: 421– 4. 3. Rose AG, Novitzky D, Price SK. Heterotopic thyroid tissue in the heart. Am J Cardiovasc Pathol 1988;1:401– 4. 4. Doria E, Agostoni P, Fiorentini C. Accessory thyroid tissue in the right ventricle. Chest 1989;96:424–5. 5. Kon ND, Headley RN, Cordell AR. Successful operative management of struma cordis obstructing the left ventricular outflow tract. Ann Thorac Surg 1988;46:244 –5. 6. Polvani GL, Antona C, Porqueddu M, et al. Intracardiac ectopic thyroid: conservative surgical treatment. Ann Thorac Surg 1993;55:1249 –51. 7. Dresler C, Werner M, Wahlers T, Borst HG. Ectopic thyroid tissue in the heart: two case reports. Dtsch Med Wochenschr 1995;120:1387–91. 8. Richmond I, Whittaker JS, Deiraniya AK, Hassan R. Intracardiac ectopic thyroid: a case report and review of published cases. Thorax 1990;45:293– 4.
Traumatic Rupture of an Aberrant Right Subclavian Artery Julian J. Alcocer, MD, Laurence Spier, MD, Cornelius M. Dyke, MD, Bartley P. Griffith, MD, and James S. Gammie, MD Division of Cardiothoracic Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts
We describe a patient who sustained a traumatic rupture of an aberrant right subclavian artery. An interposition graft was used to restore continuity of the artery to the descending thoracic aorta. (Ann Thorac Surg 2000;69:621–3) © 2000 by The Society of Thoracic Surgeons
A
n aberrant right subclavian artery (ARSA) is the most common aortic arch anomaly, with an incidence of 0.6% to 0.8% in the general population [1]. In North America, approximately 1,000 to 1,500 cases of traumatic aortic rupture, primarily because of motor vehicle crashes, are treated annually [2].
Accepted for publication June 22, 1999. Address reprint requests to Dr Gammie, Division of Cardiothoracic Surgery, University of Massachusetts Medical Center, 55 Lake Ave N, Worcester, MA 01655-0304; e-mail: [email protected].
0003-4975/00/$20.00 PII S0003-4975(99)01368-5
CASE REPORT BAYKUT ET AL ECTOPIC THYROID - HEART
Ann Thorac Surg 2000;69:620 –1
3. Czer LSC, Trento A, Blanche C, et al. Orthotopic heart transplantation: clinical experience with a new technique. J Am Coll Cardiol 1993;21(Suppl A):168A. 4. Blanche C, Valenza M, Aleksic I, Czer LSC, Trento A. Technical considerations of a new technique for orthotopic heart transplantation. J Cardiovasc Surg 1994;35:283–7. 5. Duncan JM, Miodrag M, Frazier OH. Orthotopic cardiac transplantation in patients with large donor/recipient atrial size mismatch: surgical technique. Ann Thorac Surg 1987;44: 420–1.
Ectopic Thyroid Tissue in the Left Ventricular Outflow Tract Doan Baykut, MD, Udo Fiegen, MD, Arno Krian, MD, and Andreas Thiel, MD Clinic of Thoracic and Cardiovascular Surgery, Heart Center, Duisburg, Germany
Ectopic thyroid tissue in the heart (struma cordis) is rare. The only report from a hemodynamically significant obstruction of the left ventricular outflow tract (LVOT) by a heterotopic thyroid gland was published in 1988. In our patient, a 42-year-old woman with recurrent chest pain, two spheric cardiac tumors were diagnosed by transthoracal echocardiography. One of the tumors, obstructing the LVOT, could successfully be resected under cardiopulmonary bypass. The pathologic examination showed a colloid-filled ectopic thyroid gland. The second tumor, which was entirely located in the submembraneous part of the interventricular septum, had no hemodynamic influence, and was left in situ to avoid surgical damage of adjacent intraseptal structures. The midterm follow-up showed no recurrence. (Ann Thorac Surg 2000;69:620 –1) © 2000 by The Society of Thoracic Surgeons
Fig 1. Preoperative transesophageal echocardiographic image of the left ventricular outflow tract and interventricular septum. The first tumor is located directly under the aortic valve, while the second tumor is intraseptal, thinly covered by myocardium. (AV ⫽ aortic valve; IVS ⫽ interventricular septum; LV ⫽ left ventricle; LVOT ⫽ left ventricular outflow tract; TU ⫽ tumor).
valve leaflet, obstructing the LVOT. Ventriculography and coronary angiography showed an additional, similar sized tumor in the interventricular septum to the first one. Both tumors were perfused with coronary blood, mainly from the left coronary artery. By levography, a significant obstruction of the left ventricular cavity could not be verified. The motion of both aortic and mitral valves was not restricted. The left ventricular function and coronary status were normal. Laboratory findings were within normal values, including thyroid-related hormones. The ECG showed no remarkable changes. Since the characteristics of the tumors cannot be identified by a series of conservative methods, the exploratory
T
he heterotopic occurrence of the thyroid tissue in humans is mainly originated from embryological development abnormalities of the primitive heart [1–3]. The struma cordis, or ectopic thyroid gland, in the heart is an extremely rare finding [2, 4 – 6]. In the reported cases, the ectopic thyroid noduli were found predominantly in the right ventricular wall or interventricular septum [3, 4, 7]. In patients with an obstruction of intracardiac cavities, the right ventricular outflow tract (RVOT) was mainly involved [4, 9]. Kon and associates described an ectopic thyroid tissue in the left ventricular outflow tract (LVOT) in 1988 [5], which was successfully resected under cardiopulmonary bypass. A 42-year-old woman was admitted with recurrent retrosternal pain over a 4 to 5 week period. The cardiopulmonary history was unremarkable. By transthoracal echocardiography (ECG), a small homogenous tumor (1.25 ⫻ 1.0 ⫻ 1.0 cm) was revealed under the right coronary aortic Accepted for publication June 21, 1999. Address reprint requests to Dr Baykut, Clinic of Thoracic and Cardiovascular Surgery, Heart Center, Duisburg, D-47137 Duisburg, Germany.
© 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 2. Intraoperative situs. The left ventricular outflow tract is exposed through the aortic valve. The arrow marks the tumor partly obstructing the outflow tract. 0003-4975/99/$20.00 PII S0003-4975(00)01344-2
Ann Thorac Surg 2000;69:621–3
CASE REPORT ALCOCER ET AL ABERRANT RIGHT SUBCLAVIAN ARTERY
621
these cases can only be unveiled by a functional anomaly or malignant transformation. Since silent cardiac tumors can remain undetected over a lifetime, initial subjective symptoms like pain, angina, or dyspnea, often indicate an advanced stage of the disease caused by an obstruction of intracardiac cavities and vessels or valvular dysfunction. In these cases, the surgeon should be aware of managing the dilemma of a radical therapy with severe structural cardiac damage versus conservation of the cardiac function with the risk of an incomplete operation.
References Fig 3. Transesophageal echocardiographic image after tumor resection. The left ventricular outflow tract is now free of any obstruction. The primary tumor site appears slightly excavated (arrow). The second tumor, which was left in situ, is partly visible. (AO ⫽ aorta; LVOT ⫽ left ventricular outflow tract; NCC ⫽ noncoronary cusp of the aortic valve; RCC ⫽ right coronary cusp of the aortic valve.)
cardiotomy became necessary. The transesophageal echocardiography (TEE), which was carried out before the operation, displayed the tumors clearly in size and location (Fig 1). After opening the aortic root, the first tumor could be exposed in the LVOT under the right sinus of Valsalva (Fig 2). It was spherical, with a smooth capsular surface. A complete enucleation was possible without injury of the myocardial tissue. The specimen was urgently sent to the pathologic examination. The septally located second tumor could be exposed after opening the right atrium. By bidigital transtricuspid and transaortal palpation, the tumor was localized in the submembraneous ventricular septum. The entire tumor mass was intramural, well isolated and in direct contact with important anatomical structures (bundle of His, septal coronary branches, and left ventricular dorsal wall). Any attempt to remove this tissue, even incompletely, seemed hazardous to these structures, and would lead to a severe damage. Therefore, the operation was terminated without a further tumor resection. There were no intraoperative complications. In the following TEE, the LVOT was free of any obstruction, verifying the complete removal of the first tumor (Fig 3). The pathologic examination of the specimen showed a heterotopic thyroid tissue with colloid-filled follicles of different sizes and shapes. No signs of inflammatory disease or malignant growth were found. The postoperative clinical course was also without complication. After 9 days of clinical treatment, the patient was dismissed in good condition. At 1 year follow-up, she showed continuously good hemodynamical status without recurrence of the remaining intracardiac thyroid tissue.
Comment Tumors originating from a heterotopic extracardiac tissue are extremely rare, and there is no exact data about their percental distribution. In many cases, the heterotopy exists only in traces, leading to some coincidental findings in pathologic specimens. Heterotopic tissue in © 2000 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1. Kantelip B, Lusson JR, De Riberolles C, Lamaison D, Bailly P. Intracardiac ectopic thyroid. Hum Pathol 1986;17:1293– 6. 2. Kerlan V, Jobic Y, Boschat J, Barra JA, Penther P, Bercovici JP. Intracardiac ectopic thyroid. Ann Endocrinol (Paris) 1993;54: 421– 4. 3. Rose AG, Novitzky D, Price SK. Heterotopic thyroid tissue in the heart. Am J Cardiovasc Pathol 1988;1:401– 4. 4. Doria E, Agostoni P, Fiorentini C. Accessory thyroid tissue in the right ventricle. Chest 1989;96:424–5. 5. Kon ND, Headley RN, Cordell AR. Successful operative management of struma cordis obstructing the left ventricular outflow tract. Ann Thorac Surg 1988;46:244 –5. 6. Polvani GL, Antona C, Porqueddu M, et al. Intracardiac ectopic thyroid: conservative surgical treatment. Ann Thorac Surg 1993;55:1249 –51. 7. Dresler C, Werner M, Wahlers T, Borst HG. Ectopic thyroid tissue in the heart: two case reports. Dtsch Med Wochenschr 1995;120:1387–91. 8. Richmond I, Whittaker JS, Deiraniya AK, Hassan R. Intracardiac ectopic thyroid: a case report and review of published cases. Thorax 1990;45:293– 4.
Traumatic Rupture of an Aberrant Right Subclavian Artery Julian J. Alcocer, MD, Laurence Spier, MD, Cornelius M. Dyke, MD, Bartley P. Griffith, MD, and James S. Gammie, MD Division of Cardiothoracic Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts
We describe a patient who sustained a traumatic rupture of an aberrant right subclavian artery. An interposition graft was used to restore continuity of the artery to the descending thoracic aorta. (Ann Thorac Surg 2000;69:621–3) © 2000 by The Society of Thoracic Surgeons
A
n aberrant right subclavian artery (ARSA) is the most common aortic arch anomaly, with an incidence of 0.6% to 0.8% in the general population [1]. In North America, approximately 1,000 to 1,500 cases of traumatic aortic rupture, primarily because of motor vehicle crashes, are treated annually [2].
Accepted for publication June 22, 1999. Address reprint requests to Dr Gammie, Division of Cardiothoracic Surgery, University of Massachusetts Medical Center, 55 Lake Ave N, Worcester, MA 01655-0304; e-mail: [email protected].
0003-4975/00/$20.00 PII S0003-4975(99)01368-5