Tricuspid valve endocarditis patients who undergo tricuspid valve excision, repair, and replacement have similar 30-day operative mortality, as defined by The Society of Thoracic Surgeons. Excision patients have significantly lower unplanned readmission rates at 1 year. Tricuspid valvectomy is an acceptable initial treatment in this high-risk group as part of a surgical strategy to identify patients who are candidates for eventual valve replacement. Further study of long-term outcomes and survival is warranted.
A 51-year-old female presented with a 5-month history of general weakness, fatigue, and dyspnea on exertion with increasing abdominal girth. An electrocardiogram showed normal sinus heart rhythm with left atrial enlargement. Physical examination revealed an early diastolic murmur most prominent at the apex and a pansystolic murmur.Transesophageal echocardiography revealed a large mass occupying the left atrium during systole ( Fig. 1), with occlusion of the mitral valve during diastole (Fig. 2). Severe tricuspid regurgitation was present and right heart catheterization showed pulmonary hypertension (mean pressure 44 mmHg) and elevated pulmonary capillary wedge pressure (31 mmHg).At the time of surgery, the mitral valve was exposed through the Sondergaard's groove approach and the stalk of the mass was identified lateral to the fossa ovalis and completely removed. Surgical excision revealed a 8 × 4 × 3 -cm myxoma ( Fig. 3), which required full thickness excision of the stalk as well as subsequent over-sewing of the entire fossa ovalis. Additionally, a De Vega annuloplasty of the tricuspid valve was also performed. The histopathological examination confirmed a benign cardiac myxoma consisting of myxoid soft tissue and clot with the stalk margin free from invasion. The patient had an uneventful postoperative course with immediate improvement in mean pulmonary pressure (21 mmHg), no residual tricuspid regurgitation, and no residual mass at echocardiography (Fig. 4). She was discharged on the seventh postoperative day. At 3-month follow-up, she remains asymptomatic in New York Heart Association Class I. CONFLICT OF INTERESTThe authors acknowledge no conflict of interest in the submission. How to cite this article: Gallo M, Trivedi JR, Protos AN, Slaughter MS. Massive left atrial myxoma induced congestive heart failure. J Card Surg. 2017;32:420-421. https://doi.org/10.1111/jocs.13158 FIGURE 1 Transesophageal echocardiography shows a massive myxoma in the left atrium during systole. LA, left atrium; LV, left ventricle; Myx, myxoma; RV, right ventricle FIGURE 2 Transesophageal echocardiography shows a massive myxoma occluding mitral valve during diastole. LA, left atrium; LV, left ventricle; Myx, myxoma; RV, right ventricle 420 |
The obstruction of blood flow through the superior vena cava (SVC) into the right atrium may present as a severe clinical syndrome. One of the benign causes of SVC obstruction is the long-term use of indwelling catheters and wires, increasing the chances of SVC thrombosis. The treatment of the benign SVC syndrome is focused on achieving long-term durability and patency of the superior venocaval system and normal life expectancy. We report the successful surgical management of a patient with severe symptomatic SVC syndrome and emphasize technical details that might be of value in treating this challenging pathologic condition.
Chemical tagging of amino acids is an important tool in proteomics analysis, and has been used to introduce isotope labels and mass defect labels into proteolytic peptides by derivatization of cysteine or lysine residues. Here, we present a new reagent with chemical specificity for tryptophan residues. Previously, 2-nitrobenzenesulfenyl chloride has been used as a highly specific reagent for labeling tryptophan residues. We show that this tag undergoes UV dissociation during matrix assisted laser desorption/ionization (MALDI). The multiplicity of photofragments increases the difficulty of characterizing the derivatization products. To overcome this problem, we have synthesized a new reagent, 2-(trifluoromethyl)benzenesulfenyl chloride, which is shown to react quantitatively with tryptophan in peptides and proteins. Most significantly, it exhibits high photostability in MALDI-Fourier transform mass spectrometry analyses.
Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon, benign localized fibrotic lesion. Historically, PASH has been difficult to differentiate from angiosarcoma. This difficulty has led to recommendations of surgical excision. We sought to identify the incidence of upgraded pathology to atypia or malignancy on surgical excisional biopsy after identification of PASH on core needle biopsy (CNB). A 5-year retrospective review at a single institution was conducted including all cases of PASH confirmed on CNB. The data set was divided into patients who underwent excisional biopsy and those followed only by imaging. Primary end points included the incidence of subsequent malignancy or high-risk pathology on histologic analysis or the presentation of suspicious imaging. Thirty-seven patients were reviewed, 19 (51.4%) underwent surgical excision and 18 (48.6%) were followed with imaging alone. A palpable mass was noted in 36.8 per cent of patients in the excisional group versus 5.6 per cent in the imaging group ( P = 0.02). The median follow-up for the excisional and imaging groups were 43 and 35 months, respectively ( P = 0.85). The 95 per cent confidence interval for the presence of malignancy was 0 to 9.4 per cent. Although further characterization of PASH is needed, our data support using CNB with follow-up imaging as a safe alternative to excisional biopsy in the absence of symptoms or other clinical factors. However, further research in this area is needed.
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