Case Description
A 70-year-old man presented with dyspnea on effort and lower limb edema.
Chest radiography showed cardiomegaly (cardiothoracic ratio of 57%).
Transthoracic echocardiography showed a huge mass measuring 44 × 56 mm
originating from the right atrium and right ventricle. The mass was
almost completely adhered to the tricuspid valve, resulting in moderate
stenosis with a mean pressure gradient of 9 mmHg (Video 1). Enhanced
computed tomography showed that the tumor had invaded the anterior wall
of the right atrium and right ventricle, totally involving the right
coronary artery (Figure 1A, B). The interleukin-2 receptor level was
extremely high (890 U/mL). Fluorodeoxyglucose positron emission
tomography revealed abnormal accumulation in the right atrium, right
ventricle, atrial septum near the mitral valve annulus, and intestinal
and prepericardial lymph nodes (Figure 2).
Cardiopulmonary bypass was established through ascending aortic
cannulation and bicaval drainage, and the heart was arrested. The tumor
had invaded the anterior and posterior tricuspid annulus, but not the
septal leaflet or coronary sinus. We performed complete en bloc
resection of the tumor and most of the right atrium, right ventricle,
tricuspid valve, and right coronary artery, preserving the coronary
sinus. The tricuspid septal annulus was also preserved, and we applied
several everting mattress stitches for placement of a biological valve.
A large double-folded bovine pericardial patch was then sutured to the
remaining biological cuff; one side of the patch was trimmed and sutured
to the right ventricle, while the other side was sutured to the right
atrium. Finally, coronary bypass was performed from the great saphenous
vein to the posterior descending artery (Video 2). No atrioventricular
block was present postoperatively. The operation, cardiopulmonary
bypass, and cross-clamping times were 332, 175, and 121 minutes,
respectively. Pathological examination revealed diffuse large B-cell
lymphoma.
Postoperative transthoracic echocardiography revealed no tumor or
thrombus and showed good performance of the biological valve with a mean
pressure gradient of 5 mmHg (Video 1). Postoperative enhanced computed
tomography showed a well-reorganized right atrium and right ventricle.
The patient was discharged on postoperative day 14 with no signs of
heart failure. Although the excised end of the tumor was pathologically
positive, the patient was able to receive optimal chemotherapy because
an accurate qualitative diagnosis had been obtained by surgery. The
chemotherapy resulted in a partial response at 6 months postoperatively.