박용진, 김명중, 정재훈, 서정주, 최승민, 주신배

362

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Coronary artery-left ventricle microfistulae in a patient with apical hypertrophic cardiomypathy

국립중앙의료원 순환기내과

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박용진, 김명중, 정재훈, 서정주, 최승민, 주신배

Coronary artery microfistulae are a rare anomaly. Coexistence of coronary artery–left ventricular fistulae and apical hypertrophic cardiomyopathy is very rare and can lead to serious cardiac complications owing to coronary steal phenomena such as angina pectoris, myocardial infarction, congestive heart failure. A 41-year-old woman with history of hypertension presented to our hospital e with dyspnea on exertion(New Tork Heart Association Class III) and chest pain. The B-type natriuretic peptide(BNP) level was 202 pg/ml(reference range <100pg/ml) was significantly elevated. Chest X-ray showed mild cardiomegaly. Electrocardigram demonstrated deep anterior T-wave inversion in the percordial leads. Transthoracic 2-dimensional echocardiography showed hypertropphy of apical left ventricular walls. Doppler echocardiography revealed multiple areas of diastolic color flow within the apical myocar- dium connected to the left ventricular cavity. Coronary angiography showed no significant atherosclerotic lesions; however, it revealed microfistulae origi- nated from left anterior descending coronary artery and draining into left ventricle. Left ventriculography revealed a apade-shaped cavity indicative of ap- ical hypertrophic cardiomyopathy. We treated the patient with medical therapy including vasodilators(perindopril, nicorandil),diuretics(furosemide) and be- ta-blocker(carvedilol)and her symptom improved on follow-up. This case report highlights a rare association of hypertrophic cardiopathy with coronary ar- tery fistula and it is important to recognize coronary artery fistula as the aggravating factor of angina and heart failure in patients without angiographic evi- dence of major atherosclerotic coronary artery disease.

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A case of metastatic cardiac myxoid liposarcoma

중앙보훈병원 내과

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윤주희, 박중일

73 year old man was admitted for chest pain and V1~V3 ST change which suggests LAD territory ischemia. Transthoracic echocardiograghy (TTE) re- vealed mid interventricular septal(IVS) wall thickening(25mm) with irregular surface and increased echogenicity compared with left ventricular (LV) pos- terior wall [figure 1]. He had history of Left. thigh liposarcoma operation in 2007 that was Myxoid/round cell liposarcoma. The sarcoma recurred 1 year lat- er in 2008 and was excised with adjuvant radiation therapy. After then it recurred to adjacent Lt. hip muscle and subcutaneous layer in following 2013, 2014, 2016 and was excised repeatedly at each time. He had also got right middle lobectomy about lung cancer stage I which was solid predominant in- vasive adenocarcinoma in 2012.9. So, we checked PET-CT for further evaluation for rule out cardiac liposarcoma metastasis, and PET-CT suggested Lt.

peri-renal space, omentum and left ventricle metastasis of liposarcoma [figure 1]. For metastatic cardiac liposarcoma, operation was not feasible, therefore, patient received doxorubicin/cisplatin(AP) chemotherapy two times followed by Gemcitabine/Docetaxel regimen and palliative RT to Lt. retrorenal area as disease progression. 1 year follow-up TTE showed round mass appearance with changed echogenicity of IVS from echogenic to echo-lucent [figure 2]. He was expired 4 months later in conservative treatment. Liposarcoma is a soft tissue tumor which consists 9.8~16% of sarcoma and occurs most often in the retroperitoneum and extremities. Metastasis to heart is quite rare and cardiac involvement of Myxoid liposarcoma is extremely rare. But the incidence and invasion range of metastasis can be increasing with cancer survival is increasing. Therefore, Our report emphasizes that using echocardiography is im- portant for early detection of tumor metastasis to heart.

362

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￭

Coronary artery-left ventricle microfistulae in a patient with apical hypertrophic cardiomypathy

국립중앙의료원 순환기내과

*

박용진, 김명중, 정재훈, 서정주, 최승민, 주신배

Coronary artery microfistulae are a rare anomaly. Coexistence of coronary artery–left ventricular fistulae and apical hypertrophic cardiomyopathy is very rare and can lead to serious cardiac complications owing to coronary steal phenomena such as angina pectoris, myocardial infarction, congestive heart failure. A 41-year-old woman with history of hypertension presented to our hospital e with dyspnea on exertion(New Tork Heart Association Class III) and chest pain. The B-type natriuretic peptide(BNP) level was 202 pg/ml(reference range <100pg/ml) was significantly elevated. Chest X-ray showed mild cardiomegaly. Electrocardigram demonstrated deep anterior T-wave inversion in the percordial leads. Transthoracic 2-dimensional echocardiography showed hypertropphy of apical left ventricular walls. Doppler echocardiography revealed multiple areas of diastolic color flow within the apical myocar- dium connected to the left ventricular cavity. Coronary angiography showed no significant atherosclerotic lesions; however, it revealed microfistulae origi- nated from left anterior descending coronary artery and draining into left ventricle. Left ventriculography revealed a apade-shaped cavity indicative of ap- ical hypertrophic cardiomyopathy. We treated the patient with medical therapy including vasodilators(perindopril, nicorandil),diuretics(furosemide) and be- ta-blocker(carvedilol)and her symptom improved on follow-up. This case report highlights a rare association of hypertrophic cardiopathy with coronary ar- tery fistula and it is important to recognize coronary artery fistula as the aggravating factor of angina and heart failure in patients without angiographic evi- dence of major atherosclerotic coronary artery disease.

￭

￭

A case of metastatic cardiac myxoid liposarcoma

중앙보훈병원 내과

*

윤주희, 박중일

73 year old man was admitted for chest pain and V1~V3 ST change which suggests LAD territory ischemia. Transthoracic echocardiograghy (TTE) re- vealed mid interventricular septal(IVS) wall thickening(25mm) with irregular surface and increased echogenicity compared with left ventricular (LV) pos- terior wall [figure 1]. He had history of Left. thigh liposarcoma operation in 2007 that was Myxoid/round cell liposarcoma. The sarcoma recurred 1 year lat- er in 2008 and was excised with adjuvant radiation therapy. After then it recurred to adjacent Lt. hip muscle and subcutaneous layer in following 2013, 2014, 2016 and was excised repeatedly at each time. He had also got right middle lobectomy about lung cancer stage I which was solid predominant in- vasive adenocarcinoma in 2012.9. So, we checked PET-CT for further evaluation for rule out cardiac liposarcoma metastasis, and PET-CT suggested Lt.

peri-renal space, omentum and left ventricle metastasis of liposarcoma [figure 1]. For metastatic cardiac liposarcoma, operation was not feasible, therefore, patient received doxorubicin/cisplatin(AP) chemotherapy two times followed by Gemcitabine/Docetaxel regimen and palliative RT to Lt. retrorenal area as disease progression. 1 year follow-up TTE showed round mass appearance with changed echogenicity of IVS from echogenic to echo-lucent [figure 2]. He was expired 4 months later in conservative treatment. Liposarcoma is a soft tissue tumor which consists 9.8~16% of sarcoma and occurs most often in the retroperitoneum and extremities. Metastasis to heart is quite rare and cardiac involvement of Myxoid liposarcoma is extremely rare. But the incidence and invasion range of metastasis can be increasing with cancer survival is increasing. Therefore, Our report emphasizes that using echocardiography is im- portant for early detection of tumor metastasis to heart.