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Cardiac tumors are quite rare, and differential diagnosis of them is challenging. We present the case report of a young man complaining on non specific chest pain who was reported to Cardiology Ward due to suspicion of thrombus in left ventricle. The patient's echocardiography showed an additional mobile structure located in apex of left ventricle. For further investigation he had a cardiac Magnetic Resonance Imaging (MRI) performed which drew out the suspicion of rather unmalignant tumor. Ultimately patient underwent noncomplicated cardiac surgery with total excision of the tumor. Histopatology examination reveald capillary hemangioma.

Myxomas are the most common primary cardiac tumors, with an estimated incidence of 0.5 per million per year. Familial myxoma constitutes 10% of all myxomas, among these tumors, one in ten is part of Carney complex - an autosomal dominant syndrome, which are related to some mutations in the PRKAR1A gene. We report a case of 75-year-old man with sporadic cardiac myxoma of a 4-cm large tumor, arising from the left side of the atrial septum and causing a severe left ventricle inflow obstruction. Cytogenetic analysis confirmed by fluorescence in situ hybridization method (FISH), demonstrated a numerical aberration in atrial myxoma cells: 47, XY, +21. Flow cytometry analysis demonstrated that a quarter of tumors cells were hematopoietic progenitor cells (CD34+) and that a similar number were endothelial specific neovascular cells (CD31+). These finding suggest that, hematopoietic progenitor cells may play an important role in the histogenesis of cardiac myxomas and the karyotype aberrations have an impact on sporadic tumor genesis. Nevertheless, genetic screening for sporadic (non-familial) cardiac myxomas is not recommended.

Permanent atrial fibrillation (AF) is present before operation and persists after surgery in 30-40% of patients undergoing mitral valve surgery. Using the maze procedure, 75-82% of patients can be cured of AF, but the procedure is difficult and long lasting. Percutaneous radiofrequency (RF) ablation has emerged as an effective therapy for AF in recent years.To assess the efficacy of intra-operative RF ablation of AF in patients undergoing mitral valve surgery.100 adults with permanent AF underwent mitral valve replacement. Patients were divided into two groups: the RF group--50 patients qualified for mitral valve replacement and RF ablation; and the control group--50 patients selected for mitral valve replacement without ablation. Odds ratio and 95% confidence interval were examined to assess the influence of several factors on the outcome (free from AF during one-year follow-up based on symptoms and serial Holter ECG recordings).Baseline clinical, demographic and echocardiographic characteristics were similar in both groups. Electrical cardioversion following surgery was required in 76% of patients from the RF group compared with 94% from the control group (p0.002). In those who underwent cardioversion, sinus rhythm was restored more frequently in RF than control patients (32 vs. 16%, p0.002). Sinus rhythm at hospital discharge was present in 56% of RF patients compared with 22% of controls (p=0.0001), and after one-year follow-up in 54 vs. 16% (p0.001), respectively. The use of amiodarone was significantly lower in RF patients compared with controls (32 vs. 70%, p0.05). NYHA class III (OR 8.5, CI 1.0-394) or IV (OR 36, CI 1.2-1958) and left atrial diameter6 cm (OR 9.3, CI 0.5-5230) were identified as predictors of AF.Intra-operative RF ablation performed in the left atrium in patients with chronic AF undergoing mitral valve replacement significantly improves sinus rhythm restoration rate. Advanced heart failure (NYHA class IV) and left atrial diameter6 cm are negative prognostic factors for sinus rhythm maintenance.

A 64-year-old obese female patient with no previous cardiac history was admitted to hospital due to decreased exercise tolerance. The resting electrocardiography showed atrial fibrillation (AF). In transthoracic echocardiography, mitral valve stenosis (area 1.26 cm2) with a concomitant large tumour in the left atrium (LA) was visualised (Fig. 1A). The finding was confirmed by transoesophageal echocardiography — in the LA a large homogenous massive structure was detected. It was a strand-like structure, most probably an organised thrombus, originating from the left appendage extended (diameter 20–30 mm) to the LA, where it was adherent to the left atrial wall and the mitral valve apparatus. The structure partially blocked the mitral valve orifice, enhancing pre-existing mitral valve stenosis (Fig. 1B). Tumour excision with concomitant mitral valve replacement was planned. The patient was referred to the Department of Cardiovascular UJ CM. Surgery was performed using standard cardiopulmonary bypass with moderate hypothermia and antegrade blood cardioplegia. Cardiac surgical procedure confirmed the presence of a giant thrombus located in the whole left appendage and the majority of the LA body, partially obstructing pulmonary veins (Fig. 1C, D). The pathological mitral valve was excised and an artificial mitral valve Medtronic ATS (diameter 29 mm) was placed. The left atrial appendage was ligated. Microscopic examination confirmed a giant thrombus. Left atrial thrombus is one of the typical complications of mitral stenosis; however, the number of patients with mitral stenosis is nowadays very low. On the other hand, the obstructive character of the mass is a very rare feature. Risk factors for thrombus formation in the LA, besides the mitral stenosis, are AF and an enlarged LA. It is estimated that mitral stenosis increases the risk by 17% and the coexistence of mitral stenosis with AF doubles the risk. In this group of patients, the risk of stroke is significantly increased. Although the importance of anticoagulation in prevention of recurrence is obvious, cardiac surgery seems to be the only reasonable means of treatment due to the fact that thrombi extended into the left atrial body in patients with mitral stenosis and AF may persist despite optimal anticoagulation. In conclusion, surgical removal of the thrombus is the treatment of choice. Figure 1. A. Echocardiographic four-chamber view presenting a large mass in the left atrium (arrow); B. Transoesophageal echocardiography of the left atrium at 114 degrees with a large wall adherent mass (arrow); C. Operative view after tumour resection; D. A thrombus removed from the left atrium A

The most frequent arrhythmia is an atrial fibrillation, which involves 10% of population over 70. The mortality in this group is 2 times higher than in general population. Moreover, if the atrial fibrillation co-exists with the rheumatic disease, the risk of the brain embolism is growing up 17 times. In the many European medical centers, intraoperative ablation is the obligatory procedure performed during mitral valve replacement/mitral valvuloplasty or coronary artery bypass grafting. Results of that procedure (in experienced centers) are evaluated on 75%. It reduces significantly the cost of the farther pharmacological treatment and improves the quality of life of the patients. In our Clinic ablation is performed in patients qualified to the mitral valve replacement or mitral valvuloplasty. All procedures are performed in extracorporeal circulation, in general and local hypothermia, with using crystal cardioplegine. Before the clumping of the aorta, on the beating heart ablation in the right atrium is performed. After that, the aorta is being clumped and the heart is being stopped. The left cardiac auricle is being cut off. Then the ablation around the ostia of the pulmonary veins is being done. After that, mitral valve replacement or mitral valvuloplasty procedure is being performed. Changes in the heart wall are transmural through the full wall. From the December 2001 till today 4 ablation procedures were done. Units Cobra (Boston Scientific) and Cardioblate Surgical Ablation System (Medtronic) were used. Both units are based on the unipolar energy with frequency similar to the radio-waves. After this procedure, regular rhythm came back in our 4 patients. Advantages of the intraoperative ablation are: simultaneous procedure with open heart operation, reduction of the price of the treatment, minimal risk of complication.

Objective: Through a retrospective study on the use of fresh homografts in 655 aortic valve replacement patients over a period of 23 years, we aimed to assess the reasons for eventual reoperation and causes of valve dysfunction. Methods: Between January 1980 and December 2002, 655 patients received fresh homografts. All homografts were antibiotic sterilized and stored at 4 8C. During this time, 139 patients (116 male and 23 female) with a mean age of 46.7 years (range 18– 72) required reoperation. Results: The 30-day hospital overall mortality was 2.87%. The mean durability for all homografts was 12.4 ^ 4.54 years (1 month to 23 years). The cumulative rates for freedom from reoperation for any cause were 94.09 ^ 2% at 5 years and 87.9% ^ 4% at 10 years, 76.6 at 15 years, 49.55 at 20 years. The major cause of valve dysfunction and indication for reoperation was degeneration in 111 patients (79.8%). Predominant aortic valve insufficiency in 87 patients (62.5%) and predominant stenosis in 24 patients (17.26%). Endocarditis occurred in 21 patients (15.1%). Early endocarditis was diagnosed in five patients (3.59%), late endocarditis in 16 patients (11.5%). Additional causes for reoperation included ascending aortic aneurysm, mitral valve insufficiency and congestive cardiomyopathy. Seventeen patients (12.2%) required concomitant procedures. Coronary artery bypass grafting was performed in six cases (4.3%), mitral valve replacement in five cases (3.59%), mitral valve annuloplasty in six (4.3%). The primary reoperative procedure was artificial/mechanical aortic valve implantation. In five cases, St. Jude Medical conduit grafts were implanted due to ascending aortic aneurysms. Homograft reimplantation was performed in four cases. One patient underwent mitral valve replacement and one patient received a heart transplant. Conclusion: The results of the study suggest that reoperation in patients with aortic homografts is a low-risk procedure as compared to alternative therapies. Primary allograft aortic valve replacement can give acceptable results for up to 23 years. The major cause of valve dysfunction and indication for reoperation was degeneration. Cumulative rates for freedom from reoperation for any cause in age groups suggest careful selection and indications in homograft implantation in the younger patients. Young age is a risk factor for an early homograft structural deterioration (degeneration). q 2003 Elsevier Science B.V. All rights reserved.