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We report the case of a 38-year-old woman who underwent cardiac sarcoma resection and presented later with spontaneous left ventricular free-wall rupture. The original tumor resection required autotransplantation and a transmitral approach, including partial resection of the inner left ventricular wall. Although the patient did well postoperatively, 3 weeks later she developed a large pericardial effusion with tamponade. Intraoperatively, a portion of the left ventricular free wall ruptured and required repair with a Dacron patch. The patient recovered and was discharged from the hospital 3 weeks later. To our knowledge, this is the 1st reported case of spontaneous ventricular rupture after the resection of a cardiac tumor.
Malignant primary cardiac tumors are extremely rare, and surgical resection can be challenging. Many of these tumors can be debulked; however, involvement of the ventricular free wall presents a unique challenge of how much tissue to resect safely. Here, we report the case of a 38-year-old woman who experienced spontaneous ventricular free-wall rupture after having undergone resection of a cardiac sarcoma.
In November 2007, a 38-year-old woman underwent examination for atypical chest pain and was found to have a large left ventricular sarcoma. Transesophageal echocardiography (TEE) revealed the tumor to be approximately 4 × 5 cm (Fig. 1A). Due to the large size of the tumor, her symptoms were attributed to transient left ventricular outflow tract obstruction. Surgical resection was performed, with use of an autotransplantation technique and a transmitral approach (Fig. 1B). The tumor arose from the left ventricular free wall; this required partial resection of the wall and replacement of the mitral valve, due to papillary muscle involvement. After the resection, TEE revealed normal left ventricular function and wall thickness of 6 mm during diastole, which our surgical team deemed adequate. The surgery and the patient's immediate postoperative course were uneventful, and she was discharged from the hospital after 2 weeks. Final histopathologic examination revealed the tumor to be a high-grade sarcoma, with the tumor within 1 mm of the margin (Fig. 1C).
Approximately 3 weeks after the patient's initial surgery, she presented again at the hospital with shortness of breath. A computed tomographic scan and echocardiogram revealed a large pericardial effusion with signs of tamponade. She was taken emergently to the operating room for drainage of the pericardial effusion. Intraoperatively, after the effusion was drained, she became hypotensive with a large amount of bleeding; control of the situation required an emergency sternotomy and manual compression of the rupture site. After cardiopulmonary bypass was instituted, inspection of the left ventricular free wall revealed a 2 × 2-cm rupture. There was no gross evidence of recurrent tumor, and the ventricular defect was closed by use of a Dacron patch and interrupted, pledgeted sutures (Fig. 2). The patient recovered and was discharged from the hospital 3 weeks after this operation; after 4 months, there was no tumor recurrence.
Malignant cardiac tumors portend a dismal prognosis, and the only chance for cure is complete surgical resection.2,3 High-grade sarcomas that involve the ventricular tissue are especially difficult to treat, and although surgical excision with negative margins is ideal, debulking may be the only feasible therapy. We have previously described the possible approaches to intracavitary left ventricular sarcomas, and the potential problems with the transaortic valvular or ventriculotomy route.4 Autotransplantation has also been used to resect left ventricular tumors in order to achieve the goal of negative margins.4,5 In view of the ineffectiveness of chemotherapy regimens in the treatment of cardiac malignancies, aggressive surgical resection offers the best chance for local control and the only hope for extended survival. However, aggressive surgical procedures can result in additional postoperative morbidity for the patient, including ventricular wall rupture, which occurred in our patient. Ventricular wall rupture from various types of tumor involvement has been reported.6–9 However, those tumors led to wall rupture via the involvement of coronary arteries, which resulted in infarction or direct wall erosion.
To our knowledge, this is the 1st reported case of spontaneous rupture of the ventricular free wall after cardiac tumor resection. The cause of the rupture in our patient was not recurrent tumor, but most likely a thinning of the left ventricular wall after the initial tumor resection.
As in the case of our patient, surgical removal or debulking of ventricular tumors risks weakening or thinning the ventricular wall. Cardiac wall thickness has been extensively studied as it relates to viability; in contrast, the minimal wall thickness necessary for normal function after tumor resection has not been well defined. Therefore, great care should be exercised during the surgical excision of these tumors: in order to avoid the complication that occurred in our patient, residual tumor that involves the wall may need to be left behind.
Address for reprints: Brian A. Bruckner, MD, 6550 Fannin St., Suite 1401, Houston, TX 77030. E-mail: gro.shmt@renkcurbab