A case of pulmonary vein obstruction: evaluation using newer echocardiographic imaging techniques
2nd Department of Cardiology, Athens University, Attikon Hospital, Perikleous Street 19, N. Chalkidona, Athens, 14343, Greece
Received 31 March 2007; accepted after revision 15 April 2007; online publish-ahead-of-print 31 July 2007.
* Corresponding author. Tel: +30 6944805732; fax: +30 210 5832351. E-mail address: ignoik{at}otenet.gr
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A 59-year-old woman was admitted in our hospital due to persistent cough and dyspnea. Transthoracic 2-dimensional echocardiography demonstrated a cardiac mass (29x34 mm) that extended from the right upper pulmonary vein into the left atrium causing the partial obstruction of the right lower vein as indicated by the increased Doppler velocities. Contrast echocardiography confirmed the presence of microcirculation within the mass. During transesophageal (TEE) echocardiographic study, color Doppler imaging and power Doppler imaging (Angio® Vivid 7, GE Medical System, Horten, Norway) demonstrated the presence of vascular flow within the mass. A chest magnetic resonance tomography showed a pulmonary mass of 30x25x28 mm infiltrating the pulmonary veins. After surgery, biopsy confirmed a high grade mucoepidermoid lung cancer with few large arterioles. The new echocardiographic techniques can reliably differentiate a cardiac tumor from a cardiac thrombus.
Keywords: Contrast; Color Doppler; Pulmonary vein; Cardiac mass; Left atrium; Mucoepidermoid lung cancer
A 59-year-old woman with a history of pulmonary emphysema, smoking and dyslipidemia was admitted to our hospital due to persistent cough and dyspnea since 3 months. Clinical examination and laboratory findings, including chest radiogram and electrocardiogram, were within normal limits. Transthoracic 2-dimensional echocardiography (4-chamber view) demonstrated a 29 x 34 mm mass that extended from the right pulmonary veins into the left atrium (Figure 1A). The differential diagnosis included thrombus or tumor deriving from the pulmonary veins and an ultrasound contrast agent (Sonovue) was used in order to assess the microvasculature of the mass (Figure 1B). During a continuous infusion (1 mL/min) of Sonovue (Vueject pump, BRF-INF-100, Bracco, Italy), we observed a mild uptake of the contrast agent by the mass suggesting the presence of microcirculation. The mass had occluded the right upper pulmonary vein, while partially obstructed the right lower vein, as indicated by the increased systolic and diastolic velocities measured by the pulsed wave Doppler of the right lower pulmonary vein (Figure 1C). A transesophageal (TEE) echocardiographic study revealed a heterogenous lobular mass that was filling the right upper pulmonary vein and was growing into the left atrium (Figure 2A and B). Using color Doppler imaging (Figure 3A) and power Doppler imaging (Angio® Vivid 7, GE Medical System, Horten, Norway) (Figure 3B) we demonstrated the presence of vascular flow across the mass (Figure 3, arrows). A chest magnetic resonance tomography showed an atelectatic middle lobe of the right lung and a pulmonary mass of 30 x 25 x 28 mm infiltrating the pulmonary veins. The patient underwent a middle sternotomy and excision of the left atrium mass along with a right lateral thoracotomy and excision of the upper and middle lobe of the right lung plus lymphadenectomy. Biopsy of specimens was compatible with a poorly differentiated, high grade mucoepidermoid lung cancer with a few large arterioles in agreement with our Doppler findings. The patient died 8 months after surgery due to disease progression.
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Primary cardiac tumors are rare, with a necropsy incidence of 0.05%.1 A quarter of all cardiac tumors are malignant, the majority of which are angiosarcomas and rhabdomyosarcomas. Secondary deposits are found more frequently, in 1% of postmortem examinations and mostly affect the epicardium.2 Carcinoma of lung and breast may spread by local infiltration invading usually the pericardium and rarely the cardiac muscle. Infiltration through the pulmonary veins has also been reported and is usually complicated by obstruction of the mitral valve or arterial embolisation.3–6
In our case we have observed infiltration of the pulmonary veins and growing of the mass within the vein and into the left atrium which is not a frequent finding for a mucoepidermoid lung cancer. In conclusion, we have shown that using the newer echocardiographic techniques we can reliably differentiate a cardiac tumor from a cardiac thrombus.
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