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Unusual cardiac metastasis in hypernephroma: The complementary role of echocardiography and magnetic resonance imaging
Volume Number
3.
4.
.J.
6.
7.
8.
9.
10.
11. 12.
13.
116 5. Part 1
Brief
tion, definition, diagnosis and consequences. Prog Cardiovasc Dis 1982;25:169-92. Bulkley BH, Klacsmann PG, Hutchins GM. Angina pectoris, myocardial infarction and sudden cardiac death with normal coronary arteries: a clinicopathologic study of 9 patients with progressive systemic sclerosis. AM HEART J 1978;95:563-9. Alexander EL, Firestein GS, Weiss JL, Heuser RR, Leitl G, Wagner HN Jr, Brinker JA, Ciuffo AA, Becker LC. Reversible cold-induced abnormalities in myocardial perfusion and function in systemic sclerosis. Ann Intern Med 1986;105: 661-8. Raymond R, Lynch J, Underwood D, Leatherman J, Razavi M. Myocardial infarction and normal coronary arteriography: a 10 year clinical and risk analysis of 74 patients. J Am Co11 Cardiol 1988;11:471-7. Johannessen KA, Nordrehaug JE, von der Lippe G. Left ventricular thrombosis and cerebrovascular accident in acute myocardial infarction. Br Heart J 1984;51:553-6. Weinreich DJ, Burke JF, Pauletto FJ. Left ventricular mural thrombi complicating acute myocardial infarction. Longterm follow-up with serial echocardiography. Ann Intern Med 1984;100:789-94. Arvan S. Left ventricular mural thrombi secondary to acute myocardial infarction: predisposing factors and embolic phenomenon. J Clin Ultrasound 1983;11:467-73. Nair CK, Sketch MH, Mahoney PD, Lynch JD, Mooss AN, Kenney NP. Detection of left ventricular thrombi by computerised tomography. A preliminary report. Br Heart J 1981; 45:535-41. Benichou M, Aubry J, Larbi MB, Romani A, Chiche G, Egre A, Djiane P, Bory M, Serradimigni A. Detection of left intraventricular thrombi in the acute phase of myocardial infarction by Z-dimensional echocardiography. Apropos of 103 cases. Arch Ma1 Coeur 1983;76:1012-9. Bhatnagar SK, Al Yusuf AR. Left ventricular thrombi after acute myocardial infarction. Postgrad Med J 1983$9:495-S. Tramarin R, Pozzoli M, Vecchio C. Left ventricular thrombosis in recent myocardial infarction. An echocardiographic study. G Ital Cardiol 1982;12:397-404. Asinger RW, Mike11 FL, Elsperger J, Hodges M. Incidence of left-ventricular thrombosis after acute transmural myocardial infarction. Serial evaluation by two-dimensional echocardiography. N Engl J Med 1981;305:297-302.
Unusual cardiac metastasis in hypernephroma: The complementary of echocardiography and magnetic resonance imaging
role
Aaron J. Gin&a, MD,’ Benjamin Gentin, MD, David P. Naidich, MD,” Robin S. Freedberg, MD, Dorothy McCauley, MD,” and Itzhak Kronzon, MD.” New York, N.Y.
Hypernephroma is one of several malignant, tumors that commonly involve the heart. Spread generally occurs by t,ransvenous extension from the kidney, via the renal vein and inferior vena cava and ultimately into the right atria1
Prom the Departments Medical Center.
of Medicine’
Reprint requests: Dr. Itzhak Krrnxwn. 4vr.. Suite 2E. New Yurk. NY 10016.
and
RadiologyP N.Y.U.
Medical
New
York Center.
University 560 First
Communications
1359
cavity. Hematogenous or lymphatic spread to the heart is rare. We describe a patient with right atrial metastases from a hypernephroma in the absence of vena caval involvement, documented by magnetic resonance imaging (MRI). A 74-year-old man, previously in excellent health, was noted to have significant cardiomegaly on a routine chest roentgenogram in May 1987. Echocardiography demonstrated a large pericardial effusion with evidence of diastolic right atria1 compression. This is considered an early echocardiographic sign of cardiac tamponade.’ During open surgical drainage of the pericardial effusion, a mass was noted on the wall of the right atrium and a biopsy was obtained. Pathologic examination of the mass revealed neoplastic cells with tubular and stromal elements, consistent with renal cell carcinoma. An abdominal computed tomography (CT) scan confirmed the presence of a renal mass, limited to the left kidney without renal vein involvement or other evidence of metastatic disease. Nephrectomy was recommended, but the patient refused further intervention. Six months later, follow-up echocardiography revealed a large sessile mass that filled the right atria1 cavity but did not extend to the tricuspid orifice (Fig. 1). Because this mass had not been present on the initial echocardiogram, an MRI scan was obtained to document further the nature of the abnormality. These scans were obtained with an 0.5 tesla superconducting system (Philips Gyroscan S5, Philips Medical Systems, Inc., Shelton, Conn.) that used spin echo pulse sequences with two-dimensional Fourier transform (2DFT) spatial encoding. Scans were acquired in both transaxial and coronal planes with electrocardiographic (ECG) gating. Effective repetition time (TR) was determined by the patient’s heart rate, equaling approximately 750 msec. MRI confirmed a lobular, soft tissue mass originating from the right atria1 wall and protruding into the right atria1 cavity. The mass extended into the superior vena cava, which was partially obstructed (Fig. 2). The inferior vena cava was demonstrated in its entirety in both axial and coronal planes, and was free of tumor (Fig. 2). In addition, a coronal scan of the upper abdomen demonstrated a large, heterogeneous tumor mass occupying most of the upper pole of the left kidney without demonstrable renal vein or vena cava involvement. The patient declined further intervention and continues to be asymptomatic. Approximately 23 “0 o f patients with hypernephroma have demonstrable metastatic disease at the time of the initial diagnosis.2 Inferior vena cava invasion has been documented in 9% of cases.3 Of these, as many as 14% may develop extension to the right atrium.4 Metastatic disease within the right atrium is almost invariably due to intravenous tumor extension via the inferior vena cava.5 Bryant and Vuckovics described a patient who, in addition to having obstruction of the inferior vena cava and extension of the tumor thrombus into the right atrium, had an additional, independent tumor mass loosely attached to the interatrial septum and tumor emboli in t.he pulmonary artery branches. The latter were presumed to be emboli arising from the vena caval tumor thrombus.
1360
Brief
Communications
American
November 1888 Heart Journal
Fig. 1. Two-dimensional echocardiogram (left). Apical four-chamber view demonstrating a large, lobulated mass in the right atrium. LV, left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium; TU, tumor mass.
Fig. 2. Coronal MRI image demonstrating a large mass in the region of the left kidney. The inferior vena cava, from the level of the kidney to the right atrium, is seenin its entirety and is free of tumor. A tumor massis noted in the right atrium but doesnot extend to the inferior vena cava. RT, renal tumor; RC, right renal cyst (incidentally noted); IVC, inferior vena cava; DA, descendingaorta; RA, right atrium; M, right atria1 mass;LA, left atrium; RRA, right renal artery.
occurs in 3% to 8% of clinical and autopsy cases,7but there has been only one report of malignant pericardial effusion as the sole manifestation of metastatic renal cell carcinoma.7In that patient, therapy was instituted with external beam radiation to the pericardium and radical nephrectomy. Thirty-one months after the nephrectomy, that patient had no signs of recurrence. In our patient, tumor invasion of the right atria1 wall was present at the time of discovery of the malignant pericardial effusion. The tumor continued to grow into and through the right atrial wall, resulting in the unusual intracavitary mass visualized echocardiographically and more clearly defined by MRI. Documentation of tumor extension into the renal veins, inferior vena cava, and right atrium is important in accurate tumor staging, as well as in determining appropriate surgical procedures and predicting prognosis.2-5 MRI, becauseof its distinctive multiplanar capabilities and nonreliance on contrast media to identify blood vesselsand cardiac chambers,in many respectsis an ideal modality for staging renal cell carcinoma.8zgRecently, MRI has been shown10to be superior to echocardiography in characterizing intracavitary right atrial masses.The present caseclearly demonstratesthe complementary role of echocardiography, which initially detected the pericardial effusion and later visualized the atria1 mass,and of MRI, which demonstrated the renal and atria1 masses, better defined the anatomic relations, and suggestedthe route of spread (hematogenousor lymphatic, rather then direct intravascular extension), thus providing insight into the stage of the tumor. REFERENCES
TXi, ._ _ L-.-._u.L I.... yu_Is ,;,,!& lu G,,; ally ~abebirl LOW medical literature of hypernephroma involving the right atrium in the absenceof inferior vena cava tumor extension, as seen in our patient. Metastasisto the pericardium from renal cell carcinoma
1. Kronzon I, CohenML, Winer HE. Diastolicatria1compression:a sensitivesignof cardiactamponade. J Am Co11 Cardiol i983;2:770-5. 2. RitchieAWS, deKiernanJB. The naturalhistoryandclinical featuresof renalcarcinoma.SeminNephrol1987;7:131-9. 3. Scefft P, Novick AC, Straffon RA, StewartBH. Surgeryfor vena cava. J renalcell carcinomaextendinginto the inferior Urol 1978;120:28-31.
Volume Numbsr
4.
5.
6. 7.
8.
9.
10.
116 5, Part
Brief
1
Communications
1361
Bissada NK, Finkbeiner AE, Williams GD, Weiss JB. Successful extraction of intracardiac tumor thrombus of renal carcinoma. J Urol 1977;118:474-5. Goldman A, Parmeswaran R, Kotler MN, Hartman J, Parry W. Renal cell carcinoma and right atria1 tumor diagnosed by echocardiography. AM HEART J 1985;110:183-6. Bryant J, Vuckovic G. Metastatic tumors of the endocardium. Arch Path01 Lab Med 1978;102:206-8. Schellhammer PG. El-Mahdi A. Renal cell carcinoma with solitary metastases to pericardium. Urology 1983;21:399401. Hrick H, Demas BE, Williams RD, McNamara MT, Hedgcock MW, Amparo EG, Tanagho EA. Magnetic resonance imaging in the diagnosis and staging of renal and perirenal neoplasms. Radiology 198$154:709-X. Choyke PL, Kressel HY, Pollock HM, Arger PM, Axe1 L, Mamourian AC. Focal renal masses: magnetic resonance imaging. Radiology 1984;152:471-7. Freedberg RS, Kronzon I, Rumancik W, Liebeskind D. The contribution of magnetic resonance imaging to the evaluation of intracardiac tumors diagnosed by echocardiography. Circulation 1988;77:96-103.
Two-dimensional echocardiography Lutembacher’s syndrome
in
Peter C. Yan, MB, MMed,” B. L. Chia, MB, FRACP, Arthur T. Tan, MB, FRACP,” Maurice H. Choo, MB, MRCP; H. S. Saw, MB, FRCS,b and Monica B. Tay.” Singapore, Republic of Singapore
Lutembacher’s syndrome (coexisting mitral stenosis and atria1 septal defect) is an uncommon condition that is difficult to diagnose clinically.1~2 We describe the two-dimensional echocardiographic (2D echo) abnormalities of two such patients whom we encountered recently. A 33-year-old woman was referred for breathlessness. Clinical examination revealed a long rumbling middiastolic murmur at the apex, indicating mitral stenosis. The 12-lead electrocardiogram (ECG) showed sinus rhythm and incomplete right bundle branch block. The chest x-ray film showed cardiomegaly and pulmonary plethora. 2D echo was then performed. In the parasternal long-axis view, the mitral valve leaflets were thickened and there was diastolic doming of the anterior leaflet, indicating a rheumatic etiology. The right ventricle and the left atrium were both dilated (Fig. 1). In the parasternal short-axis view, the mitral valve orifice in diastole measured 1.0 cmr. In the subcostal four-chamber view, a large secundum atria1 septal defect was seen (Fig. 1). Lutembacher’s syndrome was diagnosed. The patient was taken for surgery without cardiac catheterization. At operation, the right atrium, the right ventricle, and the main pulmonary artery were all noted to be dilated. The From “Division of Cardiology. Department of Medicine, National University Hospital, and bMount Elizabeth Medical Center. Reprint requests: Prof. B. I,. Chia, Dept. of Medicine, National University Hospital, Lower Kent Ridge Rd.. Singapore 0511, Republic of Singapore.
Fig. 1. Case No. 1. A, Pamaternal long-axis view recorded in diastole. The mitral valve leafleti (ml) are thickened. The anterior mitral valve leaflet (open &row) is domed. The left atrium (LA) and the right ventricle (RV) are dilated. LV, left ventricle; Ao, aorta. 6, Subcosti apical four-chamber view. Both the right atrium (RA) and the left atrium (LA) are dilated. Arrowheads demarcate the secundum atrial septal defect. Other abbreviations as in A.
mitral valve leaflets were thickened and the mitral valve orifice was estimated to be about 1.2 cm2. A large secundum atrial septal defect measuring 1.5 cm in diameter was also found. Open mitral commissurotomy was performed with a Tubb’s dilator. The atria1 septal defect was closed by direct suture. The patient recovered completely from the operation and was discharged from the hospital in a satisfactory condition. A 57-year-old woman presented with breathlessness. Clinical examination revealed a loud rumbling middiastolic murmur at the apex. There was also clinical evidence of severe tricuspid regurgitation. The blood pressure was 120/90 mm Hg. The 12-lead ECG showed
3.
4.
.J.
6.
7.
8.
9.
10.
11. 12.
13.
116 5. Part 1
Brief
tion, definition, diagnosis and consequences. Prog Cardiovasc Dis 1982;25:169-92. Bulkley BH, Klacsmann PG, Hutchins GM. Angina pectoris, myocardial infarction and sudden cardiac death with normal coronary arteries: a clinicopathologic study of 9 patients with progressive systemic sclerosis. AM HEART J 1978;95:563-9. Alexander EL, Firestein GS, Weiss JL, Heuser RR, Leitl G, Wagner HN Jr, Brinker JA, Ciuffo AA, Becker LC. Reversible cold-induced abnormalities in myocardial perfusion and function in systemic sclerosis. Ann Intern Med 1986;105: 661-8. Raymond R, Lynch J, Underwood D, Leatherman J, Razavi M. Myocardial infarction and normal coronary arteriography: a 10 year clinical and risk analysis of 74 patients. J Am Co11 Cardiol 1988;11:471-7. Johannessen KA, Nordrehaug JE, von der Lippe G. Left ventricular thrombosis and cerebrovascular accident in acute myocardial infarction. Br Heart J 1984;51:553-6. Weinreich DJ, Burke JF, Pauletto FJ. Left ventricular mural thrombi complicating acute myocardial infarction. Longterm follow-up with serial echocardiography. Ann Intern Med 1984;100:789-94. Arvan S. Left ventricular mural thrombi secondary to acute myocardial infarction: predisposing factors and embolic phenomenon. J Clin Ultrasound 1983;11:467-73. Nair CK, Sketch MH, Mahoney PD, Lynch JD, Mooss AN, Kenney NP. Detection of left ventricular thrombi by computerised tomography. A preliminary report. Br Heart J 1981; 45:535-41. Benichou M, Aubry J, Larbi MB, Romani A, Chiche G, Egre A, Djiane P, Bory M, Serradimigni A. Detection of left intraventricular thrombi in the acute phase of myocardial infarction by Z-dimensional echocardiography. Apropos of 103 cases. Arch Ma1 Coeur 1983;76:1012-9. Bhatnagar SK, Al Yusuf AR. Left ventricular thrombi after acute myocardial infarction. Postgrad Med J 1983$9:495-S. Tramarin R, Pozzoli M, Vecchio C. Left ventricular thrombosis in recent myocardial infarction. An echocardiographic study. G Ital Cardiol 1982;12:397-404. Asinger RW, Mike11 FL, Elsperger J, Hodges M. Incidence of left-ventricular thrombosis after acute transmural myocardial infarction. Serial evaluation by two-dimensional echocardiography. N Engl J Med 1981;305:297-302.
Unusual cardiac metastasis in hypernephroma: The complementary of echocardiography and magnetic resonance imaging
role
Aaron J. Gin&a, MD,’ Benjamin Gentin, MD, David P. Naidich, MD,” Robin S. Freedberg, MD, Dorothy McCauley, MD,” and Itzhak Kronzon, MD.” New York, N.Y.
Hypernephroma is one of several malignant, tumors that commonly involve the heart. Spread generally occurs by t,ransvenous extension from the kidney, via the renal vein and inferior vena cava and ultimately into the right atria1
Prom the Departments Medical Center.
of Medicine’
Reprint requests: Dr. Itzhak Krrnxwn. 4vr.. Suite 2E. New Yurk. NY 10016.
and
RadiologyP N.Y.U.
Medical
New
York Center.
University 560 First
Communications
1359
cavity. Hematogenous or lymphatic spread to the heart is rare. We describe a patient with right atrial metastases from a hypernephroma in the absence of vena caval involvement, documented by magnetic resonance imaging (MRI). A 74-year-old man, previously in excellent health, was noted to have significant cardiomegaly on a routine chest roentgenogram in May 1987. Echocardiography demonstrated a large pericardial effusion with evidence of diastolic right atria1 compression. This is considered an early echocardiographic sign of cardiac tamponade.’ During open surgical drainage of the pericardial effusion, a mass was noted on the wall of the right atrium and a biopsy was obtained. Pathologic examination of the mass revealed neoplastic cells with tubular and stromal elements, consistent with renal cell carcinoma. An abdominal computed tomography (CT) scan confirmed the presence of a renal mass, limited to the left kidney without renal vein involvement or other evidence of metastatic disease. Nephrectomy was recommended, but the patient refused further intervention. Six months later, follow-up echocardiography revealed a large sessile mass that filled the right atria1 cavity but did not extend to the tricuspid orifice (Fig. 1). Because this mass had not been present on the initial echocardiogram, an MRI scan was obtained to document further the nature of the abnormality. These scans were obtained with an 0.5 tesla superconducting system (Philips Gyroscan S5, Philips Medical Systems, Inc., Shelton, Conn.) that used spin echo pulse sequences with two-dimensional Fourier transform (2DFT) spatial encoding. Scans were acquired in both transaxial and coronal planes with electrocardiographic (ECG) gating. Effective repetition time (TR) was determined by the patient’s heart rate, equaling approximately 750 msec. MRI confirmed a lobular, soft tissue mass originating from the right atria1 wall and protruding into the right atria1 cavity. The mass extended into the superior vena cava, which was partially obstructed (Fig. 2). The inferior vena cava was demonstrated in its entirety in both axial and coronal planes, and was free of tumor (Fig. 2). In addition, a coronal scan of the upper abdomen demonstrated a large, heterogeneous tumor mass occupying most of the upper pole of the left kidney without demonstrable renal vein or vena cava involvement. The patient declined further intervention and continues to be asymptomatic. Approximately 23 “0 o f patients with hypernephroma have demonstrable metastatic disease at the time of the initial diagnosis.2 Inferior vena cava invasion has been documented in 9% of cases.3 Of these, as many as 14% may develop extension to the right atrium.4 Metastatic disease within the right atrium is almost invariably due to intravenous tumor extension via the inferior vena cava.5 Bryant and Vuckovics described a patient who, in addition to having obstruction of the inferior vena cava and extension of the tumor thrombus into the right atrium, had an additional, independent tumor mass loosely attached to the interatrial septum and tumor emboli in t.he pulmonary artery branches. The latter were presumed to be emboli arising from the vena caval tumor thrombus.
1360
Brief
Communications
American
November 1888 Heart Journal
Fig. 1. Two-dimensional echocardiogram (left). Apical four-chamber view demonstrating a large, lobulated mass in the right atrium. LV, left ventricle; RV, right ventricle; LA, left atrium; RA, right atrium; TU, tumor mass.
Fig. 2. Coronal MRI image demonstrating a large mass in the region of the left kidney. The inferior vena cava, from the level of the kidney to the right atrium, is seenin its entirety and is free of tumor. A tumor massis noted in the right atrium but doesnot extend to the inferior vena cava. RT, renal tumor; RC, right renal cyst (incidentally noted); IVC, inferior vena cava; DA, descendingaorta; RA, right atrium; M, right atria1 mass;LA, left atrium; RRA, right renal artery.
occurs in 3% to 8% of clinical and autopsy cases,7but there has been only one report of malignant pericardial effusion as the sole manifestation of metastatic renal cell carcinoma.7In that patient, therapy was instituted with external beam radiation to the pericardium and radical nephrectomy. Thirty-one months after the nephrectomy, that patient had no signs of recurrence. In our patient, tumor invasion of the right atria1 wall was present at the time of discovery of the malignant pericardial effusion. The tumor continued to grow into and through the right atrial wall, resulting in the unusual intracavitary mass visualized echocardiographically and more clearly defined by MRI. Documentation of tumor extension into the renal veins, inferior vena cava, and right atrium is important in accurate tumor staging, as well as in determining appropriate surgical procedures and predicting prognosis.2-5 MRI, becauseof its distinctive multiplanar capabilities and nonreliance on contrast media to identify blood vesselsand cardiac chambers,in many respectsis an ideal modality for staging renal cell carcinoma.8zgRecently, MRI has been shown10to be superior to echocardiography in characterizing intracavitary right atrial masses.The present caseclearly demonstratesthe complementary role of echocardiography, which initially detected the pericardial effusion and later visualized the atria1 mass,and of MRI, which demonstrated the renal and atria1 masses, better defined the anatomic relations, and suggestedthe route of spread (hematogenousor lymphatic, rather then direct intravascular extension), thus providing insight into the stage of the tumor. REFERENCES
TXi, ._ _ L-.-._u.L I.... yu_Is ,;,,!& lu G,,; ally ~abebirl LOW medical literature of hypernephroma involving the right atrium in the absenceof inferior vena cava tumor extension, as seen in our patient. Metastasisto the pericardium from renal cell carcinoma
1. Kronzon I, CohenML, Winer HE. Diastolicatria1compression:a sensitivesignof cardiactamponade. J Am Co11 Cardiol i983;2:770-5. 2. RitchieAWS, deKiernanJB. The naturalhistoryandclinical featuresof renalcarcinoma.SeminNephrol1987;7:131-9. 3. Scefft P, Novick AC, Straffon RA, StewartBH. Surgeryfor vena cava. J renalcell carcinomaextendinginto the inferior Urol 1978;120:28-31.
Volume Numbsr
4.
5.
6. 7.
8.
9.
10.
116 5, Part
Brief
1
Communications
1361
Bissada NK, Finkbeiner AE, Williams GD, Weiss JB. Successful extraction of intracardiac tumor thrombus of renal carcinoma. J Urol 1977;118:474-5. Goldman A, Parmeswaran R, Kotler MN, Hartman J, Parry W. Renal cell carcinoma and right atria1 tumor diagnosed by echocardiography. AM HEART J 1985;110:183-6. Bryant J, Vuckovic G. Metastatic tumors of the endocardium. Arch Path01 Lab Med 1978;102:206-8. Schellhammer PG. El-Mahdi A. Renal cell carcinoma with solitary metastases to pericardium. Urology 1983;21:399401. Hrick H, Demas BE, Williams RD, McNamara MT, Hedgcock MW, Amparo EG, Tanagho EA. Magnetic resonance imaging in the diagnosis and staging of renal and perirenal neoplasms. Radiology 198$154:709-X. Choyke PL, Kressel HY, Pollock HM, Arger PM, Axe1 L, Mamourian AC. Focal renal masses: magnetic resonance imaging. Radiology 1984;152:471-7. Freedberg RS, Kronzon I, Rumancik W, Liebeskind D. The contribution of magnetic resonance imaging to the evaluation of intracardiac tumors diagnosed by echocardiography. Circulation 1988;77:96-103.
Two-dimensional echocardiography Lutembacher’s syndrome
in
Peter C. Yan, MB, MMed,” B. L. Chia, MB, FRACP, Arthur T. Tan, MB, FRACP,” Maurice H. Choo, MB, MRCP; H. S. Saw, MB, FRCS,b and Monica B. Tay.” Singapore, Republic of Singapore
Lutembacher’s syndrome (coexisting mitral stenosis and atria1 septal defect) is an uncommon condition that is difficult to diagnose clinically.1~2 We describe the two-dimensional echocardiographic (2D echo) abnormalities of two such patients whom we encountered recently. A 33-year-old woman was referred for breathlessness. Clinical examination revealed a long rumbling middiastolic murmur at the apex, indicating mitral stenosis. The 12-lead electrocardiogram (ECG) showed sinus rhythm and incomplete right bundle branch block. The chest x-ray film showed cardiomegaly and pulmonary plethora. 2D echo was then performed. In the parasternal long-axis view, the mitral valve leaflets were thickened and there was diastolic doming of the anterior leaflet, indicating a rheumatic etiology. The right ventricle and the left atrium were both dilated (Fig. 1). In the parasternal short-axis view, the mitral valve orifice in diastole measured 1.0 cmr. In the subcostal four-chamber view, a large secundum atria1 septal defect was seen (Fig. 1). Lutembacher’s syndrome was diagnosed. The patient was taken for surgery without cardiac catheterization. At operation, the right atrium, the right ventricle, and the main pulmonary artery were all noted to be dilated. The From “Division of Cardiology. Department of Medicine, National University Hospital, and bMount Elizabeth Medical Center. Reprint requests: Prof. B. I,. Chia, Dept. of Medicine, National University Hospital, Lower Kent Ridge Rd.. Singapore 0511, Republic of Singapore.
Fig. 1. Case No. 1. A, Pamaternal long-axis view recorded in diastole. The mitral valve leafleti (ml) are thickened. The anterior mitral valve leaflet (open &row) is domed. The left atrium (LA) and the right ventricle (RV) are dilated. LV, left ventricle; Ao, aorta. 6, Subcosti apical four-chamber view. Both the right atrium (RA) and the left atrium (LA) are dilated. Arrowheads demarcate the secundum atrial septal defect. Other abbreviations as in A.
mitral valve leaflets were thickened and the mitral valve orifice was estimated to be about 1.2 cm2. A large secundum atrial septal defect measuring 1.5 cm in diameter was also found. Open mitral commissurotomy was performed with a Tubb’s dilator. The atria1 septal defect was closed by direct suture. The patient recovered completely from the operation and was discharged from the hospital in a satisfactory condition. A 57-year-old woman presented with breathlessness. Clinical examination revealed a loud rumbling middiastolic murmur at the apex. There was also clinical evidence of severe tricuspid regurgitation. The blood pressure was 120/90 mm Hg. The 12-lead ECG showed