- Email: [email protected]
Intraventricular Bronchogenic Cyst: A Rare Congenital Anomaly
Ann Thorac Surg 2015;100:1101–3
CASE REPORT FORCILLO ET AL INTRAVENTRICULAR BRONCHOGENIC CYST
References 1. Fonseca AZ, Santin S, Gomes LG, Waisberg J, Ribeiro MA Jr. Complications of radiofrequency ablation of hepatic tumors: frequency and risk factors. World J Hepatol 2014;6:107–13. 2. Luu MB, Deziel DJ. Unusual complications of gallstones. Surg Clin North Am 2014;94:377–94. 3. Park SY, Tak WY, Jeon SW, et al. The efficacy of intraperitoneal saline infusion for percutaneous radiofrequency ablation for hepatocellular carcinoma. Eur J Radiol 2010;74:536–40. 4. Kim JY, Kwon YH, Lee SJ, et al. Abscesso-colonic fistula following radiofrequency ablation therapy for hepatocellular carcinoma; a case successfully treated with histoacryl embolization [in Korean]. Korean J Gastroenterol 2011;58:270–4. 5. Bessoud B, Doenz F, Qanadli SD, Nordback P, Schnyder P, Denys A. Enterobiliary fistula after radiofrequency ablation of liver metastases. J Vasc Interv Radiol 2003;14:1581–4.
Intraventricular Bronchogenic Cyst: A Rare Congenital Anomaly ˇ
Departments of Cardiac Surgery and Pathology, Hopital SacreCoeur de Montr eal, Universite de Montr eal, Qu ebec, Canada
Intracardiac bronchogenic cyst is a rare congenital anomaly. This tumor is usually found in the mediastinum (12% to 18% of all primary mediastinal masses) or in the lung parenchyma (15% to 30% of them). Although rare, it should be included in the differential diagnosis of intracardiac tumors. Complete resection is recommended for diagnosis and for therapeutic reasons. We present here a rare case of an intracardiac left ventricular bronchogenic cyst in an asymptomatic 41-year-old woman. (Ann Thorac Surg 2015;100:1101–3) Ó 2015 by The Society of Thoracic Surgeons
I
ntracardiac bronchogenic cyst is a rare congenital anomaly. This tumor is usually found in the mediastinum (12% to 18% of all primary mediastinal masses) or in the lung parenchyma (15% to 30% of them) [1]. Although rare, it should be included in the differential diagnosis of intracardiac tumors. It is benign but may develop into malignancy [2]. Complete resection is recommended for diagnosis and for therapeutic reasons. We present here a rare case of an intracardiac left ventricular bronchogenic cyst.
at the level of the interventricular septum (IVS). It was located under the right coronary leaflet, close to the septum membranous. There was no obstruction of the left ventricular outflow tract. The left ventricular ejection fraction was normal. There was no interventricular shunt. The patient was in functional class 2, and she had never experienced any chest pain or syncope. The electrocardiogram was normal. Her doctor decided to administer anticoagulant therapy on the possibility that a thrombus could have formed in an aneurysmal portion of the IVS; a repeated TTE 3 months later showed the same image with no mass regression. She was then sent to undergo a magnetic resonance imaging scan. The mass was nonpedunculated and seemed to arise from the membranous septum. There was no gadolinium enhancement, the mass was not mobile, and it measured 1.0 1.7 1.2 cm. (Fig 1). The mass was characterised as benign with the possibility of a fibroelastoma or myxoma. The patient was informed that having an operation to remove the mass would probably cause her trouble in the future, inasmuch as it could increase her risk of having an aortic valve replacement and an atrioventricular (AV) block. The patient gave consent. The operation was performed through a median sternotomy with the patient under cardiopulmonary bypass. After the aortotomy, the mass was easily exposed. It was a cyst containing cloudy liquid with white aggregates (Fig 2). The cyst was completely resected, and the muscle deficit in the interventricular septum was reconstructed with an autologous pericardial patch. A valvuloplasty of the right leaflet of the aortic valve was also performed to repair a small perforation. There was no postoperative AV block. TTE showed no postoperative aortic insufficiency, and biventricular function remained normal. In the meantime, the microbiologist was consulted because of the purulent cyst, and he hypothesized that in consideration of the patient’s country of origin, this cyst could be a species of Echinococcus. He empirically started the antibiotic for this tapeworm and ordered a cerebral scan and abdominal echography, which were negative for other cysts. The patient’s postoperative course was uneventful. A microscopic evaluation of the cyst
A 41-year-old woman from Morocco underwent transthoracic echocardiography (TTE) prescribed by her family doctor because of a heart murmur. Her medical history included peripheral thromboemboli after pregnancy and a total thyroidectomy for a benign nodule. The TTE showed a mass (1.1 1.5 0.9 cm) under the aortic valve
Accepted for publication Nov 17, 2014. ˇ
Address correspondence to Dr Forcillo, Hopital Sacr e-Coeur de Montr eal, 5000 Belanger est, Montreal, H1T 1C8, Qu ebec, Canada; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Magnetic resonance image showing a solid mass attached to the membranous septum. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.059
FEATURE ARTICLES
Jessica Forcillo, MD, MS, Daniel Dion, MD, Camille Sauvageot, MD, and Hugues Jeanmart, MD, MS
1101
1102
CASE REPORT FORCILLO ET AL INTRAVENTRICULAR BRONCHOGENIC CYST
Ann Thorac Surg 2015;100:1101–3
FEATURE ARTICLES
Fig 2. (A) Mass visualized under the right leaflet of the aortic valve attached to the membranous septum. (B) Mass location under the right aortic leaflet.
revealed a mass surrounded by partially ciliated cuboidal and squamous epithelium (Fig 3). There was no sign of inflammation or dysplasia. The final diagnosis was a bronchogenic cyst.
Comment A bronchogenic cyst is a congenital malformation arising from the primitive foregut with an abnormal division of the tracheobronchial tree. The stage of embryonic development determines the mediastinal location. The cardiac primordia are located in close proximity to the foregut or primitive tracheobronchial tree. At this time, abnormal budding of the tracheobronchial tree may migrate to a myocardial location; bronchogenic cysts arise from such budding [3]. The cysts are usually located on the epicardial surface of the heart or within the myocardium and project into one of the cardiac cavities, more frequently on the right side [4, 5]. Bronchogenic cysts may be associated with other congenital malformations such as partial (more frequently on the left side, 70%) or total pericardial defect, patent ductus arteriosus, atrial septal defect, tetralogy of
Fallot, mitral stenosis, pulmonary sequestration, or diaphragmatic hernia [6]. As previously mentioned, those cysts are mainly found in the mediastinum and the lung parenchyma, but atypical locations such as the neck, the spinal dura mater, and the diaphragmatic region have been reported [1]. Patients are usually asymptomatic and the cyst is discovered incidentally, but some patients can present with the following symptoms: atypical chest pain, shortness of breath, arrhythmias and conduction disturbances, syncope, sudden cardiac death, and embolization according to the size and location of the cyst [7]. It is recommended to resect those cysts discovered in adults or infants because the majority will become symptomatic and complicated (hemorrhage, rupture, compression) [1]. Imaging techniques that can be used for diagnosis include TTE, transthoracic echocardiography, contrastenhanced helical computed tomography of the chest, and magnetic resonance imaging. Biopsy is not recommended because of the risk of embolization. Early resection of a bronchogenic cyst will prevent future clinical complications and is recommended because of the potential risk of malignancy development. In this case, for example, resection was uneventful, but a bigger mass could have resulted in aortic valve replacement because of more extensive involvement of the surrounding tissues.
References
Fig 3. Histopathologic view showing bronchogenic cyst with ciliated cuboidal epithelium. (Hematoxylin and eosin, 640.)
1. St-Georges R, Deslauriers J, Duranceau A, et al. Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult. Ann Thorac Surg 1991;52:6–13. 2. Endo C, Imai T, Nakagawa H, Ebina A, Kaimori M. Bronchioloalveolar carcinoma arising in a bronchogenic cyst. Ann Thorac Surg 2000;69:933–5. 3. Aktogu S, Yuncu G, Halilcolar H, Ermete S, Buduneli T. Bronchogenic cysts: clinicopathological presentation and treatment. Eur Resp J 1996;9:2017–21. 4. Weinrich M, Lausberg HF, Pahl S, Schafers HJ. A bronchogenic cyst of the right ventricular endocardium. Ann Thorac Surg 2005;79:e13–4. 5. Wei X, Omo A, Pan T, Li J, Liu L, Hu M. Left ventricular bronchogenic cyst. Ann Thorac Surg 2006;81:e13–5.
Ann Thorac Surg 2015;100:1103–5
CASE REPORT SCHROETER ET AL PROSTHETIC VALVE STENOSIS: MELODY TPV
1103
6. Voronov AA, Gavrilov SG. [Congenital absence of the pericardium in combination with bronchogenic cyst of the left lung]. [Article in Russian] Grudn Khir 1962;4:789. 7. Lee T, Tsai IC, Tsai WL, Jan YJ, Lee CH. Bronchogenic cyst in the left atrium combined with persistent left superior vena cava: the first case in the literature. AJR Am J Roentgenol 2005;185:116–9.
Prosthetic Pulmonary Valve Stenosis: A Different Way to Solve the Problem Thomas Schroeter, MD, Philipp Lurz, MD, PhD, Philipp Kiefer, MD, Mahmoud Wehbe, MD, and Ingo D€ ahnert, MD, PhD Departments of Cardiac Surgery, Cardiology, and Pediatric Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
B
ioprosthetic valves have become widely accepted for the replacement of stenotic and regurgitant native heart valves [1]. A disadvantage to these prostheses is their susceptibility to deterioration, thus warranting an additional open-heart operation. Transcatheter implantation of percutaneously delivered valves into degenerative prostheses has emerged as a plausible alternative to traditional open heart surgery in select high-risk patients. The Melody Transcatheter Pulmonary Valve (Melody TPV, Medtronic, Minneapolis, MN, USA) has been approved for the management of failing biologic prostheses, conduits, and native valve pathology in pulmonary position [2].
Fig 1. Angiography revealing the malrotation of the 2011 implanted biological pulmonary prosthesis (Medtronic Mosaic, 27 mm) with functional stenosis. For better illustration, the prosthesis framework is traced. 1 ¼ pulmonary valve prosthesis, 2 ¼ pulmonary artery, 3 ¼ aortic valve prosthesis.
patch was required to reconstruct the poor tissue quality of the right ventricular outflow tract (RVOT). In this case, prosthetic deterioration was not the reason for readmission. Catheter-based investigations illustrated atypical placement of the pulmonary prosthesis. The
We report the case of an 84-year-old man readmitted into our hospital in 2013 presenting with dyspnea, weakness, and fatigue at mild physical activity load (New York Heart Association [NYHA] class III). Relevant history included a Ross procedure in 2006 because of aortic valve stenosis in which the pulmonary valve was replaced by a biologic valve prosthesis. In 2011, the patient presented again with significant regurgitation of the aortic and pulmonary valve with a given indication for surgery. Both valves were conventionally replaced with 25- and 27-mm biologic valve prostheses (Mosaic valve; Medtronic), respectively. During this procedure, a bovine pericardial
Accepted for publication Nov 17, 2014. Address correspondence to Dr Schroeter, Heart Center Leipzig, Department of Cardiac Surgery, Struempellstrasse 39, Leipzig, D-04289, Germany; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 2. Result after implantation of the first stent (AndraStent XXL), which rotates the prosthesis toward the pulmonary artery. 1 ¼ right ventricular outflow tract; 2 ¼ sheet; 3 ¼ aortic valve prosthesis. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.065
FEATURE ARTICLES
To avoid a third major cardiovascular surgery in an 84-year-old man, a Melody Transcatheter Pulmonary Valve was implanted in a functionally stenotic bioprosthesis in the pulmonary position. The intervention was free of complications with good results. (Ann Thorac Surg 2015;100:1103–5) Ó 2015 by The Society of Thoracic Surgeons
CASE REPORT FORCILLO ET AL INTRAVENTRICULAR BRONCHOGENIC CYST
References 1. Fonseca AZ, Santin S, Gomes LG, Waisberg J, Ribeiro MA Jr. Complications of radiofrequency ablation of hepatic tumors: frequency and risk factors. World J Hepatol 2014;6:107–13. 2. Luu MB, Deziel DJ. Unusual complications of gallstones. Surg Clin North Am 2014;94:377–94. 3. Park SY, Tak WY, Jeon SW, et al. The efficacy of intraperitoneal saline infusion for percutaneous radiofrequency ablation for hepatocellular carcinoma. Eur J Radiol 2010;74:536–40. 4. Kim JY, Kwon YH, Lee SJ, et al. Abscesso-colonic fistula following radiofrequency ablation therapy for hepatocellular carcinoma; a case successfully treated with histoacryl embolization [in Korean]. Korean J Gastroenterol 2011;58:270–4. 5. Bessoud B, Doenz F, Qanadli SD, Nordback P, Schnyder P, Denys A. Enterobiliary fistula after radiofrequency ablation of liver metastases. J Vasc Interv Radiol 2003;14:1581–4.
Intraventricular Bronchogenic Cyst: A Rare Congenital Anomaly ˇ
Departments of Cardiac Surgery and Pathology, Hopital SacreCoeur de Montr eal, Universite de Montr eal, Qu ebec, Canada
Intracardiac bronchogenic cyst is a rare congenital anomaly. This tumor is usually found in the mediastinum (12% to 18% of all primary mediastinal masses) or in the lung parenchyma (15% to 30% of them). Although rare, it should be included in the differential diagnosis of intracardiac tumors. Complete resection is recommended for diagnosis and for therapeutic reasons. We present here a rare case of an intracardiac left ventricular bronchogenic cyst in an asymptomatic 41-year-old woman. (Ann Thorac Surg 2015;100:1101–3) Ó 2015 by The Society of Thoracic Surgeons
I
ntracardiac bronchogenic cyst is a rare congenital anomaly. This tumor is usually found in the mediastinum (12% to 18% of all primary mediastinal masses) or in the lung parenchyma (15% to 30% of them) [1]. Although rare, it should be included in the differential diagnosis of intracardiac tumors. It is benign but may develop into malignancy [2]. Complete resection is recommended for diagnosis and for therapeutic reasons. We present here a rare case of an intracardiac left ventricular bronchogenic cyst.
at the level of the interventricular septum (IVS). It was located under the right coronary leaflet, close to the septum membranous. There was no obstruction of the left ventricular outflow tract. The left ventricular ejection fraction was normal. There was no interventricular shunt. The patient was in functional class 2, and she had never experienced any chest pain or syncope. The electrocardiogram was normal. Her doctor decided to administer anticoagulant therapy on the possibility that a thrombus could have formed in an aneurysmal portion of the IVS; a repeated TTE 3 months later showed the same image with no mass regression. She was then sent to undergo a magnetic resonance imaging scan. The mass was nonpedunculated and seemed to arise from the membranous septum. There was no gadolinium enhancement, the mass was not mobile, and it measured 1.0 1.7 1.2 cm. (Fig 1). The mass was characterised as benign with the possibility of a fibroelastoma or myxoma. The patient was informed that having an operation to remove the mass would probably cause her trouble in the future, inasmuch as it could increase her risk of having an aortic valve replacement and an atrioventricular (AV) block. The patient gave consent. The operation was performed through a median sternotomy with the patient under cardiopulmonary bypass. After the aortotomy, the mass was easily exposed. It was a cyst containing cloudy liquid with white aggregates (Fig 2). The cyst was completely resected, and the muscle deficit in the interventricular septum was reconstructed with an autologous pericardial patch. A valvuloplasty of the right leaflet of the aortic valve was also performed to repair a small perforation. There was no postoperative AV block. TTE showed no postoperative aortic insufficiency, and biventricular function remained normal. In the meantime, the microbiologist was consulted because of the purulent cyst, and he hypothesized that in consideration of the patient’s country of origin, this cyst could be a species of Echinococcus. He empirically started the antibiotic for this tapeworm and ordered a cerebral scan and abdominal echography, which were negative for other cysts. The patient’s postoperative course was uneventful. A microscopic evaluation of the cyst
A 41-year-old woman from Morocco underwent transthoracic echocardiography (TTE) prescribed by her family doctor because of a heart murmur. Her medical history included peripheral thromboemboli after pregnancy and a total thyroidectomy for a benign nodule. The TTE showed a mass (1.1 1.5 0.9 cm) under the aortic valve
Accepted for publication Nov 17, 2014. ˇ
Address correspondence to Dr Forcillo, Hopital Sacr e-Coeur de Montr eal, 5000 Belanger est, Montreal, H1T 1C8, Qu ebec, Canada; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Magnetic resonance image showing a solid mass attached to the membranous septum. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.059
FEATURE ARTICLES
Jessica Forcillo, MD, MS, Daniel Dion, MD, Camille Sauvageot, MD, and Hugues Jeanmart, MD, MS
1101
1102
CASE REPORT FORCILLO ET AL INTRAVENTRICULAR BRONCHOGENIC CYST
Ann Thorac Surg 2015;100:1101–3
FEATURE ARTICLES
Fig 2. (A) Mass visualized under the right leaflet of the aortic valve attached to the membranous septum. (B) Mass location under the right aortic leaflet.
revealed a mass surrounded by partially ciliated cuboidal and squamous epithelium (Fig 3). There was no sign of inflammation or dysplasia. The final diagnosis was a bronchogenic cyst.
Comment A bronchogenic cyst is a congenital malformation arising from the primitive foregut with an abnormal division of the tracheobronchial tree. The stage of embryonic development determines the mediastinal location. The cardiac primordia are located in close proximity to the foregut or primitive tracheobronchial tree. At this time, abnormal budding of the tracheobronchial tree may migrate to a myocardial location; bronchogenic cysts arise from such budding [3]. The cysts are usually located on the epicardial surface of the heart or within the myocardium and project into one of the cardiac cavities, more frequently on the right side [4, 5]. Bronchogenic cysts may be associated with other congenital malformations such as partial (more frequently on the left side, 70%) or total pericardial defect, patent ductus arteriosus, atrial septal defect, tetralogy of
Fallot, mitral stenosis, pulmonary sequestration, or diaphragmatic hernia [6]. As previously mentioned, those cysts are mainly found in the mediastinum and the lung parenchyma, but atypical locations such as the neck, the spinal dura mater, and the diaphragmatic region have been reported [1]. Patients are usually asymptomatic and the cyst is discovered incidentally, but some patients can present with the following symptoms: atypical chest pain, shortness of breath, arrhythmias and conduction disturbances, syncope, sudden cardiac death, and embolization according to the size and location of the cyst [7]. It is recommended to resect those cysts discovered in adults or infants because the majority will become symptomatic and complicated (hemorrhage, rupture, compression) [1]. Imaging techniques that can be used for diagnosis include TTE, transthoracic echocardiography, contrastenhanced helical computed tomography of the chest, and magnetic resonance imaging. Biopsy is not recommended because of the risk of embolization. Early resection of a bronchogenic cyst will prevent future clinical complications and is recommended because of the potential risk of malignancy development. In this case, for example, resection was uneventful, but a bigger mass could have resulted in aortic valve replacement because of more extensive involvement of the surrounding tissues.
References
Fig 3. Histopathologic view showing bronchogenic cyst with ciliated cuboidal epithelium. (Hematoxylin and eosin, 640.)
1. St-Georges R, Deslauriers J, Duranceau A, et al. Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult. Ann Thorac Surg 1991;52:6–13. 2. Endo C, Imai T, Nakagawa H, Ebina A, Kaimori M. Bronchioloalveolar carcinoma arising in a bronchogenic cyst. Ann Thorac Surg 2000;69:933–5. 3. Aktogu S, Yuncu G, Halilcolar H, Ermete S, Buduneli T. Bronchogenic cysts: clinicopathological presentation and treatment. Eur Resp J 1996;9:2017–21. 4. Weinrich M, Lausberg HF, Pahl S, Schafers HJ. A bronchogenic cyst of the right ventricular endocardium. Ann Thorac Surg 2005;79:e13–4. 5. Wei X, Omo A, Pan T, Li J, Liu L, Hu M. Left ventricular bronchogenic cyst. Ann Thorac Surg 2006;81:e13–5.
Ann Thorac Surg 2015;100:1103–5
CASE REPORT SCHROETER ET AL PROSTHETIC VALVE STENOSIS: MELODY TPV
1103
6. Voronov AA, Gavrilov SG. [Congenital absence of the pericardium in combination with bronchogenic cyst of the left lung]. [Article in Russian] Grudn Khir 1962;4:789. 7. Lee T, Tsai IC, Tsai WL, Jan YJ, Lee CH. Bronchogenic cyst in the left atrium combined with persistent left superior vena cava: the first case in the literature. AJR Am J Roentgenol 2005;185:116–9.
Prosthetic Pulmonary Valve Stenosis: A Different Way to Solve the Problem Thomas Schroeter, MD, Philipp Lurz, MD, PhD, Philipp Kiefer, MD, Mahmoud Wehbe, MD, and Ingo D€ ahnert, MD, PhD Departments of Cardiac Surgery, Cardiology, and Pediatric Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
B
ioprosthetic valves have become widely accepted for the replacement of stenotic and regurgitant native heart valves [1]. A disadvantage to these prostheses is their susceptibility to deterioration, thus warranting an additional open-heart operation. Transcatheter implantation of percutaneously delivered valves into degenerative prostheses has emerged as a plausible alternative to traditional open heart surgery in select high-risk patients. The Melody Transcatheter Pulmonary Valve (Melody TPV, Medtronic, Minneapolis, MN, USA) has been approved for the management of failing biologic prostheses, conduits, and native valve pathology in pulmonary position [2].
Fig 1. Angiography revealing the malrotation of the 2011 implanted biological pulmonary prosthesis (Medtronic Mosaic, 27 mm) with functional stenosis. For better illustration, the prosthesis framework is traced. 1 ¼ pulmonary valve prosthesis, 2 ¼ pulmonary artery, 3 ¼ aortic valve prosthesis.
patch was required to reconstruct the poor tissue quality of the right ventricular outflow tract (RVOT). In this case, prosthetic deterioration was not the reason for readmission. Catheter-based investigations illustrated atypical placement of the pulmonary prosthesis. The
We report the case of an 84-year-old man readmitted into our hospital in 2013 presenting with dyspnea, weakness, and fatigue at mild physical activity load (New York Heart Association [NYHA] class III). Relevant history included a Ross procedure in 2006 because of aortic valve stenosis in which the pulmonary valve was replaced by a biologic valve prosthesis. In 2011, the patient presented again with significant regurgitation of the aortic and pulmonary valve with a given indication for surgery. Both valves were conventionally replaced with 25- and 27-mm biologic valve prostheses (Mosaic valve; Medtronic), respectively. During this procedure, a bovine pericardial
Accepted for publication Nov 17, 2014. Address correspondence to Dr Schroeter, Heart Center Leipzig, Department of Cardiac Surgery, Struempellstrasse 39, Leipzig, D-04289, Germany; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 2. Result after implantation of the first stent (AndraStent XXL), which rotates the prosthesis toward the pulmonary artery. 1 ¼ right ventricular outflow tract; 2 ¼ sheet; 3 ¼ aortic valve prosthesis. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.065
FEATURE ARTICLES
To avoid a third major cardiovascular surgery in an 84-year-old man, a Melody Transcatheter Pulmonary Valve was implanted in a functionally stenotic bioprosthesis in the pulmonary position. The intervention was free of complications with good results. (Ann Thorac Surg 2015;100:1103–5) Ó 2015 by The Society of Thoracic Surgeons