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Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
LETTER TO EDITOR  
Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 302-303
Transesophageal echocardiography images of right ventricular sarcoma


Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry, India

Click here for correspondence address and email

Date of Web Publication1-Oct-2013
 

How to cite this article:
Varadharajan R, Parida S, Adinarayanan S, Badhe AS. Transesophageal echocardiography images of right ventricular sarcoma. Ann Card Anaesth 2013;16:302-3

How to cite this URL:
Varadharajan R, Parida S, Adinarayanan S, Badhe AS. Transesophageal echocardiography images of right ventricular sarcoma. Ann Card Anaesth [serial online] 2013 [cited 2020 Jan 29];16:302-3. Available from: http://www.annals.in/text.asp?2013/16/4/302/119190


The Editor,

A 17-year-old female presented with a history of breathlessness (New York Heart Association class III), palpitations, syncope and low grade fever of 1 month duration. Transthoracic echocardiography (TTE) showed a mass arising from the interventricular septum and extending into the right ventricular outflow tract (RVOT). Two attempts of echocardiography guided biopsy were unsuccessful; therefore, surgical excision of the tumor was planned. Patient was induced and intubated uneventfully. Intraoperatively, on transesophageal echocardiography (TEE) imaging, RV mass lesion was seen arising from the RV septum, which infiltrated and engulfed the tricuspid septal leaflet [Figure 1] and [Figure 2]. Mass was partially excised along with the septal leaflet of the tricuspid valve. Thrombus in the RVOT and right atrium was also excised [Figure 3]. Biopsy of the excised mass revealed it to be a low grade spindle cell sarcoma. Postoperatively patient developed free tricuspid regurgitation and complete heart block because of the involvement of the tricuspid valve and atrioventricular groove.
Figure 1: Mid esophageal 4 chamber view showing right ventricular mass

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Figure 2: Mid esophageal 4 chamber view showing right ventricular sarcoma involving the tricuspid valve. Pericardial effusion is also seen

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Figure 3: Bicaval view with a small portion of mass projecting into the right ventricular. Right atrial spontaneous echo contrast can also be seen

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The treatment of primary cardiac sarcomas with chemotherapy or radiotherapy is not rewarding in terms of survival. Surgery with complete excision provides some degree of survival benefit. [1] The main anesthetic consideration is to remember that while inducing these patients complete obstruction to blood flow can occur either at valvular or outflow tract level which may result in intractable hypotension and cardiac arrest. [2] Therefore, necessity of percutaneous bypass (fem-fem bypass) should be considered prior to inducing these patients. All anesthetics should be given in a slow and titrated manner and antiarrhythmic drugs and defibrillator should be kept ready to manage malignant arrhythmias in the critical pre-bypass period. Pericardial effusion is likely to be present. Tumor metastasis is not uncommon with these sarcomas at presentation. [3] Lung parenchyma should be screened with the contrast-enhanced computed tomography for possible metastasis in any patient with respiratory compromise or poor room air blood gas. The complete excision of the tumor is not without complications. The excision can result in damage to the valvular leaflets causing regurgitation, which may necessitate valve replacement. Reconstruction of involved ventricle may result in ventricular dysfunction, which may cause difficulty in weaning off bypass. Permanent pacing may be needed in patients with damage to the conducting tissue either by tumor or during surgery. Bypass grafts may be required in case of involvement of coronaries. [4]

To summarize, cardiac sarcomas present a challenge for both anesthesiologist and surgeon. Meticulous planning is necessary for better outcomes in such cases, although overall prognosis is poor since the tumor is very aggressive and usually incurable at the time of diagnosis. [5]

 
   References Top

1.Devbhandari MP, Meraj S, Jones MT, Kadir I, Bridgewater B. Primary cardiac sarcoma: Reports of two cases and a review of current literature. J Cardiothorac Surg 2007;2:34.  Back to cited text no. 1
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2.Reshma MB, Hemant PP, Nandkumar A, Anil GT, Jaya D, Amoo S. Cardiac sarcomas: Is tumor debulking justifiable therapy? Asian Cardiovasc Thorac Ann 1999;7:52-5.  Back to cited text no. 2
    
3.Mayer F, Aebert H, Rudert M, Königsrainer A, Horger M, Kanz L, et al. Primary malignant sarcomas of the heart and great vessels in adult patients - A single-center experience. Oncologist 2007;12:1134-42.  Back to cited text no. 3
    
4.Blackmon SH, Patel A, Reardon MJ. Management of primary cardiac sarcomas. Expert Rev Cardiovasc Ther 2008;6:1217-22.  Back to cited text no. 4
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5.Bakaeen FG, Jaroszewski DE, Rice DC, Walsh GL, Vaporciyan AA, Swisher SS, et al. Outcomes after surgical resection of cardiac sarcoma in the multimodality treatment era. J Thorac Cardiovasc Surg 2009;137:1454-60.  Back to cited text no. 5
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Correspondence Address:
Ramesh Varadharajan
Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.119190

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  [Figure 1], [Figure 2], [Figure 3]



 

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