Following the written path – a patient’s journey to
finding care!
Dear Editor,
Incidental cardiac tumor is mostly diagnosed on autopsies as majority of
the patients remain asymptomatic during their lifetime.[1] But when
an incidental primary cardiac tumor is diagnosed, it not only poses
serious medical as well as ethical challenges to care team, an otherwise
asymptomatic patient himself may become surprised and rather baffled
with such an unexpected yet critical diagnosis. Information technology
(IT) and internet connectivity have made significant advancement in our
society over last two decades. Modern medicine has benefitted by the
advancement in IT and internet connectivity too. I was very surprised to
receive an email from 32 year old cardio healthy gentleman that he has
been recently given a diagnosis of an incidental cardiac tumor that was
caught by a computerized tomography (CT) scan done for kidney stone work
up. Given the rarity of the situation and his asymptomatic status,
further work up including magnetic resonant imaging (MRI) and
transthoracic echocardiography (TTE) were performed to confirm the
diagnosis. When all these imaging were suggestive of a cardiac tumor
despite not being able to conclusively delineate the extent and nature
of the tumor, this young, tech-savvy patient started reading about
primary cardiac tumor. That is when he came across my previous article
‘Near Total Occlusion of Right Ventricle by Cardiac Mass ’ which
was published at Journal of Cardiothoracic and Vascular Anesthesia
(JCVA) and knowing that we both are geographically from the same state
(MD), he emailed me if I can connect him with some cardiothoracic (CT)
surgery experts (Figure 1). [2]
I was very surprised to receive that request however, I suggested him
few of the renowned CT surgeons who are well known for cardiac tumor
surgery at my institutions. Few weeks later, he was scheduled for
surgical resection of the cardiac tumor with one of the surgeons, I
recommended and oddly enough, I was assigned to be his CT
anesthesiologist.
Upon induction of an uneventful general endotracheal anesthesia and
placement of lines, a transesophageal echocardiography (TEE) was
performed. TEE showed a well-defined left ventricular mass abutting the
lateral wall measuring approximately 3 cm by 2 cm. (Figure 2; Video 1).
There was concern for antero-lateral (AL) papillary muscle as well
mitral valve apparatus involvement, but TEE was able to demonstrate that
most of cordal attachment to AL papillary muscle was not invaded by the
tumor and intact (Video 2). TEE also showed normal biventricular
function along with absence of mitral regurgitation (MR) (Video 3).
After establishment of cardiopulmonary bypass (CPB), he
underwent ventriculotomy lateral to apex of the left ventricle, and he
was found to have a soft yellow mass at the base of the anterolateral
(AL) papillary muscle with no clear plane between mass and muscle. The
mass was resected, and it appeared to not significantly affect the
papillary muscle or mitral valve (MV) apparatus. He had an
uneventful weaning off from CBP. His post CPB TEE showed normal
biventricular function and no significant mitral regurgitation. (Video
4). Histopathology examination of the resected mass has been reported to
a lipoma, mixed with some hamartomatous component (benign).
Primary cardiac tumor is very rare and most of the incidental cardiac
tumor is diagnosed on autopsy.[1] However, when an incidental
cardiac tumor is diagnosed, it can be challenging decision for patient
as well as care team, especially surgical resection of the same involves
a major surgery including assistance of cardiopulmonary bypass and
sternotomy. Cardiac lipoma is a benign primary cardiac tumor and it is
second most common in that category following myxoma.[3] Lipoma can
be of epicardial, pericardial or subendocardial origin.[4]
Symptomatology depends on location and size of the lipoma. [5]
In this case, an educated, asymptomatic, young but baffled patient by
reviewing literature reached out to author/anesthesiologist of an
article on cardiac mass. While I am glad to be able to help the patient
out, fair share of credit goes to advancement of IT and easy internet
access.