E ECHO ROUNDS
Visceral Pericardial Lipoma Involving the Great Cardiac Vein with Large Pericardial Effusion Yosuke Kuzukawa, MD,* Toshiyuki Sawai, MD, PhD,* Junko Nakahira, MD, PhD,* Masayuki Oka, MD,* Yusuke Kusaka, MD,* and Toshiaki Minami, MD, PhD*
A
77-year old woman was hospitalized for evaluation of a large pericardial effusion of unknown etiology detected on transthoracic echocardiography without clinical evidence of heart failure. Computed tomography (CT) revealed a 20-mm × 20-mm, solid mass on the posterolateral wall of the heart with no evidence of cardiac compression (Fig. 1). No evidence of coronary artery disease or abnormal myocardial function was noted on coronary angiography and left ventriculography. Based on imaging, drainage of the pericardial effusion and biopsy of the mass were planned. After induction of general anesthesia, pressures obtained by pulmonary artery catheter were normal except for a slightly increased central venous pressure (13 mm Hg). Transesophegeal echocardiography (TEE)
Video 2. The great cardiac vein involved visceral pericardial lipoma draining into the coronary sinus. Color flow Doppler imaging. We confirmed that the circular structure in the mass was the great cardiac vein draining into the coronary sinus.
Video 1. Two-dimensional and color flow Doppler imaging of the visceral pericardial lipoma involving the great cardiac vein with large pericardial effusion. Two dimensional and color flow Dopplerimaging. The visceral pericardial lipoma has homogeneous high internal echogenicity and involves the great cardiac vein.
From the *Department of Anesthesiology, Osaka Medical College, Osaka, Japan. Accepted for publication June 19, 2012. Funding: None. The authors declare no conflicts of interest. Patient Consent Statement: Informed consent was received from the patient to publish the report. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.anesthesiaanalgesia.org). Address correspondence and reprint requests to Toshiyuki Sawai, MD, PhD, 2-7 Daigaku-machi, Takatsuki, Osaka 569–8686, Japan.1 Address e-mail to
[email protected]. Copyright © 2012 International Anesthesia Research Society DOI: 10.1213/ANE.0b013e31826a0ffc
December 2012 • Volume 115 • Number 6
Figure 1. Computed tomography. The visceral pericardial lipoma is located on the posterolateral wall of the heart (arrow). There is a large global quantity of pericardial effusion in the pericardial cavity. Ao = descending aorta; Es = esophagus; LA = left atrium; LV = left ventricle.
demonstrated normal cardiac function. The mass was evaluated by TEE, via the midesophageal short-axis view, and we later slightly withdrew and rotated the probe to the left. It was confirmed to be a broad-based, mobile extracardiac mass with homogenous high echogenicity with large global pericardial effusion (Fig. 2, A and Supplemental Video 1 http://links.lww.com/AA/A457). Color flow Doppler imaging revealed a circular vascular structure in the mass www.anesthesia-analgesia.org 1279
E ECHO ROUNDS
Figure 2. Intraoperative transesophageal echocardiography. A, Two-dimensional imaging, midesophageal short-axis (ME SAX) view demonstrating the visceral pericardial lipoma with pericardial effusion. The visceral pericardial lipoma on the posterolateral wall of the heart has homogeneous high echogenicity. B, Color flow Doppler imaging, ME SAX view demonstrating the visceral pericardial lipoma involving the great cardiac vein. After the aliasing velocity was set at 20 cm/sec, a circular vessel in the visceral pericardial lipoma was diagnosed as the great cardiac vein draining into the coronary sinus. (Please refer to Video 2.) LV = left ventricle.
(Fig. 2, B). After adjusting the aliasing velocity of the color flow Doppler, and by gradually retroflexing and rotating the TEE probe to the right, we confirmed that the vascular structure was the great cardiac vein draining into the coronary sinus (Supplemental Video 2 http://links.lww. com/AA/A458). After sternotomy, approximately 600 cc of nonsanginous pericardial effusion was drained. A soft yellow mass was noted to be adherent to the visceral pericardium. Because we anticipated that it would be too difficult to remove the mass even when using cardiopulmonary bypass, we performed a biopsy of the mass. Biopsy of the mass revealed it to be a benign visceral pericardial lipoma, and cytologic analysis of the pericardial effusion was also benign. The patient recovered uneventfully and on 5-month follow-up was asymptomatic with no signs of recurrence of the pericardial effusion.
Table 1. Differential Diagnosis of Cardiac Tumors in the Pericardial Cavity Diagnosis Angiofibroma Fibroma Hemangioma Lipoma Lymphangioma Teratoma Fibrosarcoma Liposarcoma Mesothelioma
Benign or malignant Benign Benign Benign Benign Benign Benign or malignant Malignant Malignant Malignant
Echocardiographic appearances of the internal area Nonhomogeneous echogenicity with high echogenic nodule Nonhomogeneous echogenicity Nonhomogeneous echogenicity Homogeneous high echogenicity Homogeneous high echogenicity Nonhomogeneous echogenicity Nonhomogeneous echogenicity Nonhomogeneous echogenicity Laminar
DISCUSSION
Visceral pericardial lipoma, a rare tumor that comprises 10% of primary cardiac benign tumors including the pericardial space, presents as an encapsulated mass with a macroscopic appearance of mature fat cells with fibrous and mixed tissues of varying degrees.1,2 It may also be diagnosed as “lipomatous hypertrophy” of the atrial septum or diffuse fatty infiltration of the myocardium; nevertheless, these forms are not considered to be true neoplasms.3 The slow subclinical growth of this type of tumor often delays recognition until it has already grown to a considerable size.4 Echocardiographic evaluation is helpful in the differential diagnosis (Table 1).5,6 Lipoma usually has uniform echogenicity consistent with adipose tissue with an absence of cystic elements and TEE demonstrates comparative homogeneous high internal echogenic area. Preoperative magnetic resonance imaging may be helpful in the diagnosis of visceral pericardial lipoma. In this case, the presence of a large pericardial effusion led to the detection of the pericardial mass on CT. Although the relationship of the visceral pericardial lipoma and pericardial effusion has not been
1280 www.anesthesia-analgesia.org
Figure 3. Schema of the coronary sinus and the great cardiac vein. The great cardiac vein is the largest of the veins draining into the coronary sinus. It runs over the left margin of the heart in the atrioventricular groove to merge with the left end of the coronary sinus. The coronary sinus runs transversely in the atrioventricular groove behind the left atrium. CS = coronary sinus; GCV = great cardiac vein; RA = right atrium.
ANESTHESIA & ANALGESIA
Visceral Pericardial Lipoma with Pericardial Effusion
established in the literature, we speculate an inflammatory response to the visceral pericardial lipoma may have occurred. Cytologic analysis of the fluid failed to confirm other etiologies such as malignancy or infection.7 Visualization of involvement of the great cardiac vein and coronary sinus within the lipoma by TEE was an important finding influencing the surgical procedure. Neither preoperative transthoracic echocardiography nor CT were able to detect this given the limits in resolution. CT imaging did reveal the location of the visceral pericardial lipoma on the posterolateral wall of the heart. Because the coronary sinus runs transversely in the atrioventricular groove, it is visualized in the midesophageal long-axis planes as a longitudinal structure draining into the right atrium at a zero degree multiplane orientation. In this patient we diagnosed the vascular structure as circular, consistent with the great cardiac vein because of its size and location (Fig. 3). It is possible that this finding may have been present on the patient’s preoperative coronary angiography in the delayed phase of contrast washout. In conclusion, intraoperative TEE was instrumental for diagnosis and decision making in this patient with a large visceral pericardial lipoma. E DISCLOSURES
Name: Yosuke Kuzukawa, MD. Contribution: This author helped prepare the manuscript. Name: Toshiyuki Sawai, MD, PhD. Contribution: This author helped prepare the manuscript. Name: Junko Nakahira, MD, PhD. Contribution: This author helped prepare the videos.
Clinician’s Key Teaching Points
Name: Masayuki Oka, MD. Contribution: This author helped prepare the references. Name: Yusuke Kusaka, MD. Contribution: This author helped prepare the videos and figures. Name: Toshiaki Minami, MD, PhD. Contribution: This author helped prepare the manuscript and performed a native check. This manuscript was handled by: Martin J. London, MD. ACKNOWLEDGMENTS
We appreciate Dr. Yoshihiro Takeda for the assessment. REFERENCES 1. Kelly DJ, Ramachandran S, Arya S. Epicardial lipoma mimicking pericardial effusion. Heart 2007;93:612 2. Alkan LM, Metin M, Yener A, Gokgoz L, Cengel A, Dortlemez O, Dortlemez H. A case of pericardial lipoma diagnosed by noninvasive techniques. Jpn Heart J. 1991;35:745–9 3. Hsieh TC, Schiller NB, Joshi RV. Extensive lipomatous hypertrophy of the interatrial septum with involvement of the right atrium. Anesth Analg 2010;110:725–6 4. Yamamoto T, Nejima J, Ino T, Takano T, Hayashi H, Bessho R, Sugisaki Y: A case of massive left atrial lipoma occupying pericardial space. Jpn Heart J. 2004;45:715–21 5. Kindl TF, Hassan AM, Booth RL Jr., Durham SJ, Papadimos TJ. A primary high-grade pleomorphic pericardial liposarcoma presenting as syncope and angina. Aneth Analg 2006;102:1363–4 6. Araoz PA, Mulvagh SL, Tazelaar HD, Julsrud PR, Breen JF. CT and MR imaging of benign primary cardiac neoplasms with echocardiographic correlation. Radiographics 2000;20:1303–19 7. Sagristà-Sauleda J, Mercé AS, Soler-Soler J. Diagnosis and management of pericardial effusion. World J Cardiol 2011;26:135–43
By Kent H. Rehfeldt, MD, Martin M. Stechert, MD, and Martin J. London, MD
• V isceral lipoma is an uncommon primary tumor of the pericardial space presenting as an encapsulated mass of mature fat cells and fibrous tissue. A homogenous, highly echogenic texture, lack of cystic elements, and slow, asymptomatic growth characterize this benign neoplasm. Non-neoplastic processes, such as fatty infiltration of the myocardium or lipomatous hypertrophy of the atrial septum, can be distinguished from visceral pericardial lipoma by lack of well-defined margins and typical locations. The association of pericardial effusion with visceral lipoma is not well established. • W hile magnetic resonance imaging and high-resolution computed tomography are the “gold standard” for imaging of pericardial tumors, echocardiography confers the additional benefit of real-time dynamic imaging which can be valuable when examining the hemodynamic effect of pericardial masses and/or effusions. If a fluid-filled structure is encountered, the addition of color and/or spectral Doppler may assist in determining its identity and origin. • In this case, intraoperative transesophegeal echocardiography (TEE) performed during pericardial exploration demonstrated a vascular structure encircled by a pericardial solid mass. Careful manipulation of the TEE probe along with color Doppler imaging using a reduced aliasing velocity helped identify the vascular structure as the great cardiac vein, a major contributor to the coronary sinus. Given the vascular involvement and after confirmation of the benign nature of this tumor, resection was not performed. • In addition to location, echocardiographic features such as echogenicity, the presence of well-defined margins, and homogeneity of texture help distinguish various types of cardiac neoplasms. TEE can be valuable in the differentiation of fluid-filled structures, such as cysts versus vessels, as in this case.
December 2012 • Volume 115 • Number 6
www.anesthesia-analgesia.org 1281
