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The Right Ventricular Myxoma Which Attached to the Tricuspid Valve: Sliding Tricuspid Valvuloplasty

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ISSN: 2233-601X (Print) ISSN: 2093-6516 (Online)

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1

Department of Thoracic and Cardiovascular Surgery, Kosin University Gospel Hospital,

2

Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sunkyunkwan University School of Medicine

Received: July 7, 2014, Revised: August 4, 2014, Accepted: August 7, 2014, Published online: June 5, 2015

Corresponding author: Wook Sung Kim, Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sunkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Korea

(Tel) 82-2-3410-3488 (Fax) 82-2-3410-0089 (E-mail) wooksungkim@yahoo.com

C

The Korean Society for Thoracic and Cardiovascular Surgery. 2015. All right reserved.

CC

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creative- commons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The Right Ventricular Myxoma Which Attached to the Tricuspid Valve: Sliding Tricuspid Valvuloplasty

Seong Ho Cho, M.D.

1

, Man-Shik Shim, M.D.

2

, Wook Sung Kim, M.D.

2

We report a rare case of an extremely large right ventricular myxoma involving the ventricular side of the tricuspid valve. The tumor was excised along with the entire posterior leaflet and part of the anterior leaflet. The tricuspid valve was repaired by sliding valvuloplasty combined with ring annuloplasty.

Key words: 1. Myxoma 2. Heart ventricles

CASE REPORT

Myxomas are the most common benign cardiac tumors, typically originating from the left atrium. The right atrium is the second most common site where myxomas originate, ac- counting for 7%–12% of cases [1]. Only a few cases of myx- omas arising from the right ventricle have been reported. In these cases, myxomas originating from the right ventricle usually obstruct the right ventricular outflow tract, which may cause pulmonary embolism, syncope, and sudden death. In the present case, a myxoma was found to originate from the right ventricular inlet and showed dense adhesion to the ante- rior and posterior tricuspid leaflets.

A 59-year-old man was admitted to the hospital with a three-month history of chest discomfort. An initial laboratory work-up, including complete blood count, electrolyte level, and cardiac enzyme level, revealed all results to be within normal ranges. Transthoracic echocardiography revealed a large ovoid-shaped mass in the right ventricle, approximately 4.7×3.3 cm in size. The mass was attached to the inlet portion

of the right ventricular free wall and to the anterior leaflet of the tricuspid valve (Fig. 1A). However, no tricuspid in- sufficiency or stenosis was observed, and the right ventricular systolic pressure was 21 mmHg. The patient was referred to the department of thoracic and cardiovascular Surgery for sur- gical management. A median sternotomy was performed and conventional cardiopulmonary bypass was instituted with mod- erate hypothermia. After right atriotomy, an extremely large right ventricular mass was found. The mass was attached both to the ventricular surface of the tricuspid valve, along the en- tire posterior leaflet and one third of the anterior leaflet, and to the right ventricular free wall (Fig. 1B). The mass was re- moved, and the posterior leaflet and one third of the anterior leaflet were excised as well. An incision was made along the annulus of the tricuspid valve that anchored the remaining an- terior leaflet (Fig. 2A). Several compression sutures were in- serted to reduce the annulus for sliding annuloplasty, and su- tures were placed for ring annuloplasty. The base of the ante- rior leaflet was attached to the annulus with 5-0 prolene su- tures and a tricuspid annuloplasty ring was placed (Fig. 2B).

Korean J Thorac Cardiovasc Surg 2015;48:228-230 □ How to Do It □

http://dx.doi.org/10.5090/kjtcs.2015.48.3.228

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Myxoma in the Right Ventricle

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Fig. 1. Preoperative echocardiography and intraoperative findings. (A) A transthoracic long axis view shows a mass in the right ventricle attached to the tricuspid valve. (B) Intraoperative aspect of the tumor adherent to the right ventricular free wall. The mass was attached to the ventricular surface of the tricuspid valve along the entire posterior leaflet and to one third of the anterior leaflet.

Fig. 2. Operative procedures. (A) An incision was made along the annulus of the tricuspid valve that anchored the remaining anterior leaflet. Several compression sutures were inserted to reduce the annulus in order to perform sliding annuloplasty. (B) The base of the an- terior leaflet was attached to the annulus with 5-0 prolene sutures, and sutures were placed for ring annuloplasty.

Fig. 3. Postoperative echocardiography. Postoperative echocardiog- raphy reveals minimal tricuspid regurgitation and no residual mass.

Intraoperative transesophageal echocardiography revealed no remaining tumor and no evidence of tricuspid regurgitation (Fig. 3). The patient was discharged without complications.

DISCUSSION

Myxomas arising from the right ventricle are extremely rare, and usually cause symptoms that result from obstructing the right ventricular outflow tract (RVOT). Obstruction of the RVOT and the main pulmonary trunk may cause complica- tions such as syncope, pulmonary embolism, and sudden death [2-4]. Several previous reports have described right ventricular myxomas obstructing the RVOT. However, in our case, an extremely large myxoma was located in the inlet portion of the right ventricle, with a dense adhesion to the anterior and posterior leaflets of the tricuspid valve. It is thought that this dense adhesion to the tricuspid valve and the location of the myxoma in the inlet restricted the mobility of the mass and helped to avoid RVOT obstruction.

Similarly, Hirota et al. [5] described a case of right ven-

tricular myxoma that injured the tricuspid valve, leading to

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Seong Ho Cho, et al

− 230 − massive tricuspid regurgitation. Unlike atrial myxoma, ven- tricular myxoma occasionally involves the valvular or sub- valvular apparatus, which makes surgery more complex. We had three surgical options for managing a myxoma that in- volved the tricuspid valve: tricuspid valvectomy without pros- thetic valve replacement, tricuspid valvuloplasty with partial excision of the tricuspid valve, and tricuspid valvectomy with prosthetic valve replacement. Arbulu and Asfaw [6] reported excellent results after using tricuspid valvectomy alone to treat tricuspid endocarditis, although 10%–30% of patients subsequently required tricuspid valve replacement. We de- cided to perform tricuspid valvuloplasty because the remain- ing valve leaflet was sufficient for repair and the patient wanted a procedure involving repair of the valve leaflet in or- der to avoid anticoagulation therapy. In the present case, the entire posterior leaflet and one third of the anterior leaflet was attached to the mass, and we performed sliding valvulo- plasty to excise the mass and surrounding tissue. Two-dimen- sional echocardiography is useful in the diagnosis of myxoma and in determining the site, size, mobility, and attachment of masses. The treatment of choice for myxomas is surgical ex- cision and the reported recurrence rate is 1%–3%. In con- clusion, this case study reports our surgical experience treat- ing a rare type of right ventricular myxoma.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

REFERENCES

1. Bortolotti U, Mazzucco A, Valfre C, Valente M, Pennelli N, Gallucci V. Right ventricular myxoma: review of the liter- ature and report of two patients. Ann Thorac Surg 1982;33:277-84.

2. Gopal AS, Arora NS, Messineo FC. Right ventricular myxoma. N Engl J Med 2000;342:295.

3. Kern JH, Aguilera FA, Carlson DL, Galantowicz M. Right ventricular myxoma obstructing the right ventricular outflow tract. Circulation 2000;102:E14-5.

4. Karagounis A, Sarsam M. Myxoma of the free wall of the right ventricle: a case report. J Card Surg 2005;20:73-6.

5. Hirota J, Akiyama K, Taniyasu N, et al. Injury to the tricus- pid valve and membranous atrioventricular septum caused by huge calcified right ventricular myxoma: report of a case.

Circ J 2004;68:799-801.

6. Arbulu A, Asfaw I. Tricuspid valvulectomy without pros-

thetic replacement: ten years of clinical experience. J Thorac

Cardiovasc Surg 1981;82:684-91.

수치

Fig. 1. Preoperative echocardiography and intraoperative findings. (A) A transthoracic long axis view shows a mass in the right ventricle  attached to the tricuspid valve

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