International Journal of Cardiology. 37 (1992)
115-117 0 1992 Elsevier Science Publishers B.V. All rights reserved 0167-5273/92/$05.00
CARD10 15383
Giant epicardial lipoma Jibah Eng, Kenneth Ruiz and Philip H. Kay Department of Cardiothoracic Surgery, Leeds General Infirmary, Leeds. UK
(Received 17 May 1992;accepted 18 May 1992)
A patient undergoing coronary artery bypass grafting was found to have a giant epicardial lipoma weighing 1.36 kg which was excised uneventfully. The radiological and pathophysiological features are considered. and the options for management discussed. Key words: Cardiac surgery; Epicardial tumor; Lipoma
Introduction
Cardiac lipomas are rare turnours. They may occur subendocardially, subepicardially or from the myocardium [l]. The majority of patients are asymptomatic. Large tumours may impair ventricular function resulting in dyspnoea or fatigue [2]. Infiltration of the ventricular wall may result in conduction abnormalities or dysrhythmias [3]. We report our recent experience of managing a patient with a giant epicardial lipoma.
Case Report
A 66-yr-old man presented with an 18 month history of increasing angina not associated with significant breathlessness. His chest radiograph showed a large cardiac silhouette (Fig. 3). An echocardiogram confirmed a small pericardial effusion, together with fat anteriorly. Cardiac catheterization showed moderate left ventricular function with inferior hypokinesia. Coronary arteriography revealed triple-vessel disease.
Correspondence
to: J. Eng. Dept. of Cardiothoracic
Surgery, Castle Hill Hospital. Cottingham, N. Humberside HU16 5JQ. UK.
After routine preparation, a median sternotomy was performed. On opening the pericardium, a giant epicardial lipoma was found covering the left side of the heart extending posteriorly. His cardiac index, measured by thermodilution via a pulmonary artery catheter, was 1.2 I/min/m’ after commencement of anaesthesia. This increased to 1.8 I/min/m’ with an infusion of dobutamine at 5 lg/kg/min. On opening the pericardium, the cardiac index immediately improved to 3.4 I/min/m’. The tumour was found attached to the heart at the junction of the left anterior coronary artery and its diagonal branch. The tumour was excised leaving its epicardial attachment (Fig. 2). The specimen weighed 1.36 kg. Coronary artery bypass grafting was then performed in the normal way. The patient made an uneventful postoperative recovery and was discharged well 8 days following surgery. The final histology of the specimen confirmed lipoma with no evidence of malignancy. Discussion
The presence of such a large intrapericardial tumour mass might have been expected to produce more symptoms in this patient. These were probably masked by the limitations from the severity of the ischaemic
Fig. 1. Preoperative
chest radiography
showing
enlarged
Fig. 2. The excised giant lipoma.
cardiac
silhouette
117 heart disease. The unusual radiographic picture appreciated preoperatively was not helped with echocardiography. Computed tomography scanning would have defined the tumour more accurately and has been shown to be superior to echocardiography in assessing pericardial tumours [4]. Magnetic resonance imaging may give even better visualization of cardiac masses [5]. Involvement of coronary arteries may render cardisc
lipomas
non-resectable
[l].
The
presence
of
a
giant lipoma in our patient was obviously causing some dcgrce of tamponade, as demonstrated by the improved cardiac output on opening the pericardium. Accurate diagnosis, using computed tomography and magnetic resonance imaging if available, would allow better planning and surgical management.
lnternutionul Journal of Cardiology, 37 (1992) 1 I7- 120 (!? 1992 Elsevier Science Publishers B.V. All rights reserved
CARD10
References
1 Hananouchi
GI, Goff WB. Cardiac lipoma: six-year followup with MRI characteristics, and a review of the literature. Magn Reson Imaging 1990$:825-X28.
2 Harjola
P-Tm, Ala-Kulju K, Ketonen P. Epicardial lipoma. Stand J Thor Cardiovasc Surg 3985;19:lXl-183. 3 Conces DJ, Vix VA. Tarter RD. Diagnosis of a myocardial lipoma by using CT. Am J Roentgen01 1989;153:725-726. 4 Dawson WB, Mayo JR. Miiller NL. Computed tomography of cardiac and pericardial tumours. Can Assoc Radio1 J 1990:41:270-275. 5 Moncada R, Baker M, Salinas M et al. Diagnostic role of computed tomography in pericardial heart disease: congenital defects, thickening, neoplasms. and effusions. Am Heart J 1982:103:263-2X2.
0167.5273/92/$05.00
15384
Radiofrequency ablation of incessant ventricular tachycardia to prevent multiple defibrillator shocks Luc Jordaens, Patrick Vertongen and Frank Provenier Department of Cardiology, Unicwsity Hospital Ghent, Ghent, Belgium (Received
17 May 1992; accepted
18 May 1992)
In a patient who received frequent shocks from an implantable defibrillator, a slow ventricular tachycardia originating in a large left ventricular aneurysm was ablated with radiofrequency current. Pacemapping perfectly matched the spontaneous, incessant arrhythmia. Local entrainment was present, along with a mid-diastolic potential of 65 pV. Application of 30 W terminated tachycardia within 12 s. He had no more recurrences during follow-up. Key words:
Ablation;
Implantable
cardioverter
defibrillator;
A 71-yr-old patient who had received an implantable cardiac defibrillator 13 months ago, was suddenly shocked several times by the device. Hitherto, he
Correspondence to: L. Jordaens, M.D., Dept. of Cardiology, University Hospital Ghent, De Pintelaan 185, B-9000 Ghent, Belgium. Tel. 32 91 403459. Fax 32 91 404966.
Radiofrequency
current;
Ventricular
tachycardia
had only experienced sporadic shocks from the Ventak 1600 unit (Cardiac Pacemakers Inc., St. Paul, USA). The implantable cardioverter defibrillator was implanted because of recurrent ventricular tachycardia with a rate of 200 beats/min and right bundle branch block pattern with left axis. This was due to chronic ischaemic heart disease with an inferior myocardial infarction. During the observation period immediately
115-117 0 1992 Elsevier Science Publishers B.V. All rights reserved 0167-5273/92/$05.00
CARD10 15383
Giant epicardial lipoma Jibah Eng, Kenneth Ruiz and Philip H. Kay Department of Cardiothoracic Surgery, Leeds General Infirmary, Leeds. UK
(Received 17 May 1992;accepted 18 May 1992)
A patient undergoing coronary artery bypass grafting was found to have a giant epicardial lipoma weighing 1.36 kg which was excised uneventfully. The radiological and pathophysiological features are considered. and the options for management discussed. Key words: Cardiac surgery; Epicardial tumor; Lipoma
Introduction
Cardiac lipomas are rare turnours. They may occur subendocardially, subepicardially or from the myocardium [l]. The majority of patients are asymptomatic. Large tumours may impair ventricular function resulting in dyspnoea or fatigue [2]. Infiltration of the ventricular wall may result in conduction abnormalities or dysrhythmias [3]. We report our recent experience of managing a patient with a giant epicardial lipoma.
Case Report
A 66-yr-old man presented with an 18 month history of increasing angina not associated with significant breathlessness. His chest radiograph showed a large cardiac silhouette (Fig. 3). An echocardiogram confirmed a small pericardial effusion, together with fat anteriorly. Cardiac catheterization showed moderate left ventricular function with inferior hypokinesia. Coronary arteriography revealed triple-vessel disease.
Correspondence
to: J. Eng. Dept. of Cardiothoracic
Surgery, Castle Hill Hospital. Cottingham, N. Humberside HU16 5JQ. UK.
After routine preparation, a median sternotomy was performed. On opening the pericardium, a giant epicardial lipoma was found covering the left side of the heart extending posteriorly. His cardiac index, measured by thermodilution via a pulmonary artery catheter, was 1.2 I/min/m’ after commencement of anaesthesia. This increased to 1.8 I/min/m’ with an infusion of dobutamine at 5 lg/kg/min. On opening the pericardium, the cardiac index immediately improved to 3.4 I/min/m’. The tumour was found attached to the heart at the junction of the left anterior coronary artery and its diagonal branch. The tumour was excised leaving its epicardial attachment (Fig. 2). The specimen weighed 1.36 kg. Coronary artery bypass grafting was then performed in the normal way. The patient made an uneventful postoperative recovery and was discharged well 8 days following surgery. The final histology of the specimen confirmed lipoma with no evidence of malignancy. Discussion
The presence of such a large intrapericardial tumour mass might have been expected to produce more symptoms in this patient. These were probably masked by the limitations from the severity of the ischaemic
Fig. 1. Preoperative
chest radiography
showing
enlarged
Fig. 2. The excised giant lipoma.
cardiac
silhouette
117 heart disease. The unusual radiographic picture appreciated preoperatively was not helped with echocardiography. Computed tomography scanning would have defined the tumour more accurately and has been shown to be superior to echocardiography in assessing pericardial tumours [4]. Magnetic resonance imaging may give even better visualization of cardiac masses [5]. Involvement of coronary arteries may render cardisc
lipomas
non-resectable
[l].
The
presence
of
a
giant lipoma in our patient was obviously causing some dcgrce of tamponade, as demonstrated by the improved cardiac output on opening the pericardium. Accurate diagnosis, using computed tomography and magnetic resonance imaging if available, would allow better planning and surgical management.
lnternutionul Journal of Cardiology, 37 (1992) 1 I7- 120 (!? 1992 Elsevier Science Publishers B.V. All rights reserved
CARD10
References
1 Hananouchi
GI, Goff WB. Cardiac lipoma: six-year followup with MRI characteristics, and a review of the literature. Magn Reson Imaging 1990$:825-X28.
2 Harjola
P-Tm, Ala-Kulju K, Ketonen P. Epicardial lipoma. Stand J Thor Cardiovasc Surg 3985;19:lXl-183. 3 Conces DJ, Vix VA. Tarter RD. Diagnosis of a myocardial lipoma by using CT. Am J Roentgen01 1989;153:725-726. 4 Dawson WB, Mayo JR. Miiller NL. Computed tomography of cardiac and pericardial tumours. Can Assoc Radio1 J 1990:41:270-275. 5 Moncada R, Baker M, Salinas M et al. Diagnostic role of computed tomography in pericardial heart disease: congenital defects, thickening, neoplasms. and effusions. Am Heart J 1982:103:263-2X2.
0167.5273/92/$05.00
15384
Radiofrequency ablation of incessant ventricular tachycardia to prevent multiple defibrillator shocks Luc Jordaens, Patrick Vertongen and Frank Provenier Department of Cardiology, Unicwsity Hospital Ghent, Ghent, Belgium (Received
17 May 1992; accepted
18 May 1992)
In a patient who received frequent shocks from an implantable defibrillator, a slow ventricular tachycardia originating in a large left ventricular aneurysm was ablated with radiofrequency current. Pacemapping perfectly matched the spontaneous, incessant arrhythmia. Local entrainment was present, along with a mid-diastolic potential of 65 pV. Application of 30 W terminated tachycardia within 12 s. He had no more recurrences during follow-up. Key words:
Ablation;
Implantable
cardioverter
defibrillator;
A 71-yr-old patient who had received an implantable cardiac defibrillator 13 months ago, was suddenly shocked several times by the device. Hitherto, he
Correspondence to: L. Jordaens, M.D., Dept. of Cardiology, University Hospital Ghent, De Pintelaan 185, B-9000 Ghent, Belgium. Tel. 32 91 403459. Fax 32 91 404966.
Radiofrequency
current;
Ventricular
tachycardia
had only experienced sporadic shocks from the Ventak 1600 unit (Cardiac Pacemakers Inc., St. Paul, USA). The implantable cardioverter defibrillator was implanted because of recurrent ventricular tachycardia with a rate of 200 beats/min and right bundle branch block pattern with left axis. This was due to chronic ischaemic heart disease with an inferior myocardial infarction. During the observation period immediately
