Endoscopic Resection of Malignant Fibrous Histiocytoma in Left Ventricle
An asymptomatic 58-year-old woman was admitted because of a left ventricular tumor detected on the echocardiogram. The tumor was in contact with a pedicle arising from the ventricular septum. Pulmonary arteriography showed that the oval tumor mass moved freely during the cardiac cycle. Three-dimensional CT was useful to uncover the entire image of the tumor (Figure 1⇓). Selective coronary angiography revealed 2 arteries feeding into the tumor from septal branches (Figure 2⇓). The risk of systemic thromboembolism or sudden death due to tumor embolism was an indication for surgery. Under total cardiopulmonary bypass, transaortic resection of the tumor was performed without ventriculotomy. A 30° endoscope measuring 5.3 mm in diameter was inserted via the aortotomy. The left ventricular chamber was almost entirely occupied by the tumor (Figure 3⇓, top). The tumor was not in contact with mitral valve leaflets, chordae tendineae, papillary muscles, or left ventricular endocardium. When the tumor was drawn down to the free wall by forceps, a pedicle of the tumor was clearly seen to be arising from the midportion of the ventricular septum close to the posterior papillary muscle. The pedicle was carefully resected with endoscopic scissors (Figure 3⇓, bottom). The tumor was yellow-gray, measured 30×28×25 mm, and weighed 8.0 g. Endoscopic observation was again performed to ascertain the absence of residual tumor. Operation time, cardiopulmonary bypass time, and aortic clamping time were 180, 70, and 42 minutes, respectively. Mechanical respiratory support was removed 6 hours after the surgery, and no blood transfusion was needed. A postoperative echocardiogram and left ventriculography did not reveal the existence of left ventricular tumor. Close postoperative follow-up is necessary. Histological findings demonstrated a lobulated, polypoid mass with a cellular proliferation of spindle-shaped fibroblasts and pleomorphic histiocytoid cells, often with a storiform pattern. Microscopic study disclosed a storiform-pleomorphic type of malignant fibrous histiocytoma (Figure 4⇓). There were prominent vascularity and myxoid changes in the stroma. Immunohistochemically, tumor cells were positive for vimentin and negative for desmin, S-100 protein, and α1-smooth muscle actin.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke’s Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.
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