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Year : 2010  |  Volume : 13  |  Issue : 2  |  Page : 165-166
A large angiosarcoma of the right atrium involving tricuspid valve and right ventricle


Department of Cardiac Anesthesiology, 7th Floor, CN Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India

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Date of Web Publication3-May-2010
 

How to cite this article:
Nath MP, Dhawan N, Chauhan S, Kiran U. A large angiosarcoma of the right atrium involving tricuspid valve and right ventricle. Ann Card Anaesth 2010;13:165-6

How to cite this URL:
Nath MP, Dhawan N, Chauhan S, Kiran U. A large angiosarcoma of the right atrium involving tricuspid valve and right ventricle. Ann Card Anaesth [serial online] 2010 [cited 2021 Apr 23];13:165-6. Available from: https://www.annals.in/text.asp?2010/13/2/165/62941


A 25-year-old gentle man, asymptomatic until the past two months, presented at our emergency department with breathlessness, severe chest pain, loss of appetite, abdominal distension, and pedal edema. On examination, he appeared pale with raised jugular venous pressure. There was an ejection systolic murmur at the left 2 nd and 3 rd intercostal space. The X-ray of the chest revealed large pericardial effusion and transthoracic echocardiography revealed a large mass in the right atrium (RA) (95 Χ 62 mm), which appeared to be attached with the intraatrial septum and projecting into the right ventricular cavity through tricuspid valve (TV). The tumor appeared to produce a gradient of 13 mm Hg across the TV and diastolic right ventricular outflow tract (RVOT) collapse was observed. The left ventricular function was normal. Pericardiocentesis was performed under local anesthesia to relieve the symptoms and 1,200 ml of straw colored fluid was drained. Pericardial pigtail drain was inserted to facilitate continuous drainage. The patient appeared to have symptomatic relief from this; he was scheduled for elective excision of RA mass using cardiopulmonary bypass (CPB). After induction of general anesthesia, a multiplane transesophageal echocardiography (TEE) probe was placed in the upper esophageal position. There was minimal pericardial effusion. When the probe was positioned at the mid esophageal level, a mass measuring 9 Χ 6 cm 2 was found occupying most of the RA with extension to RV through the TV [Figure 1] and [Figure 2]. Intraoperatively, the RA mass was infiltrating all over the wall of RA, TV, and right ventricle (RV). After adequate heparinization, CPB was instituted in the standard fashion. After producing a cardioplegic arrest, the RA was opened, the TEE finding were confirmed. Partial resection of the mass was possible and it required partial excision of TV. After the completion of the surgery, surgical hemorrhage was encountered from the cut edges of the RA wall. Postoperative TEE revealed that RA and RV were partially tumor free. Severe tricuspid regurgitation and severe RV dysfunction were also observed. Dobutamine (5-10 μgm/kg/min) and Sodium nitroprusside (0.5 μgm/kg/min) were started at rewarming. Heparin was reversed with Protamine and termination of CPB became possible after addition of Noradrenaline (0.1 μgm/kg/min) infusion to maintain hemodynamics. At the termination of CPB, while breathing 100% Oxygen, the pO 2 was 247 mm Hg, with SpO 2 (99%), pCO 2 (30 mm Hg), and p H (7.45) with heart rate 100 beats/min and BP (90-100/50-60 mm Hg). Post CPB red blood cells, platelet concentrate and fresh frozen plasma were started to maintain RA pressure between 8-10 mm Hg and to correct for the continued bleeding into the pericardial cavity. Postoperatively, the patient was shifted to intensive care unit (ICU) and mechanical ventilation continued with pressure regulated volume control (PRVC) mode with full inotropic support. Noradrenaline infusion was increased upto 0.2 μgm/kg/min in response to hemodynamic fluctuations. In ICU, the patient developed persistent hypotension (systolic BP 40-50 mm Hg) not responding to volume and inotropes along with Adrenaline 0.2 μgm/kg/min with diffuse continuous bleeding in the pericardial cavity. Patient had sudden cardiac arrest after about three hours and cardiopulmonary resuscitation (CPR) was started, but the patient did not respond to the treatment. The histopathology report of the tumor mass confirmed the diagnosis of angiosarcoma.

Occurence of primary cardiac tumor is rare; approximately 95% of all primary malignant cardiac tumors are sarcomas. Angiosarcoma is the most common primary cardiac malignant tumor and is an extremely rare, rapidly spreading vascular tumor. It is seen more commonly in males than in females, usually presenting between the third and fifth decade of life. [1],[2] The location of cardiac tumors varies according to the type of tumor. [3] Malignant tumors are located mainly on the right side of the heart. 90% of angiosarcomas are located in the RA with a high incidence of pericardial involvement. [4] This predilection of the tumor affecting the right heart often produces right-sided congestive heart failure, superior vena cava obstruction and pericardial effusion. In this reported case, the tumor was found arising from the RA presenting with pericardial effusion and symptoms of right heart failure.

Anesthetic considerations in patients with right atrial tumors include hypoxemia, low cardiac output, possible right to left shunt, and potential pulmonary emboli. These patient's symptomatology can be exacerbated by changes in body position. There is no gold standard for the anesthetic management of right atrial angiosarcoma, the optimal management depends on the judicious administration of anesthetic drugs, that do not cause any cardiac depression and maintenance of preload. After induction of general anesthesia, it is necessary to obtain additional venous access to continue with aggressive fluid resuscitation and blood pressure control. Central venous catheterization in the head and neck was avoided in this case given the high risk of disturbing the atrial mass and showering septic emboli into the pulmonary circulation. In our patient we choose the femoral venous route. Some authors prefer the antecubital vein without advancement of the central venous cannula to the full distance to assess central pressure and deliver medications centrally.

TEE is a useful imaging modality for assessment of cardiac masses. High resolution and the proximity between the transducer and heart provide superior evaluation of the tissue characteristics of cardiac masses compared to transthoracic echocardiography. [5] The availability of intraoperative TEE examination played useful role in the management of this patient. The presence of a large atrial mass caused severe tricuspid regurgitation, rendering the central venous pressure (CVP) measurement unreliable for evaluation of the volume status. TEE monitoring during surgical manipulation of the heart also helped in early detection and diagnosis of tumor fragmentation, dislodgement, or embolization, which may have fatal consequences and hinder weaning from CPB. TEE monitoring during surgical removal of the mass also helped to ensure the existence of residual atrial septal defects after surgical closure. [6]

 
   References Top

1.Silverman NA. Primary cardiac tumor. Ann Surg 1980;191:127-38.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Amonkar GP, Deshpande JR. Cardiac angiosarcoma. Cardiovasc Pathol 2006;15:57-8.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Meng Q, Lai H, Lima J, Tong W, Qian Y, Lai S. Echocardiography and pathologic characteristics of primary cardiac tumors: A study of 149 cases. Int J Cardiol 2002;84:69-75.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Shapiro LM. Cardiac tumors: Diagnosis and management. Heart (British Cardiac Society) 2001;85:218.   Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Huang J, Bouvette MJ, Zhou J, Dwyer GJ 3rd, Bhopatkar S, Bhatia A. A large angiosarcoma of the right atrium. Anesth Analg 2009;108:1755-7.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Riad MG, Parks JD, Murphy PB, Thangathurai D. Infected atrial myxoma presenting with septic shock. J Cardiothorac Vasc Anesth 2005;19:508-11.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Mridu Paban Nath
Department of Cardiac Anesthesiology, 7th Floor, CN Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi -110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.62941

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