CARDIAC TUMOURS, PERICARDIUM & AORTA Staff Members of Cardio-thoracic Surgery Departments Egypt

CARDIAC TUMOURS Types: Primary Benign (75%): Myxoma, rhabdomyoma, fibroma, lipoma, teratoma, Papillary fibroelastoma. Malignant (25%): - Sarcomas(rhabdomyosarcoma is the most common cardiac tumour in children) - Teratoma. Metastatic (more common) Carcinoma (lung, breast). Sarcoma. Melanoma.

CARDIAC TUMOURS (cont.) Myxoma The commonest cardiac tumour (75%). It is either smooth, firm, spherical, encapsulated mass or loose gelatinous material. It is solitary (90%), pedunculated (80%) and attached to the septum in the left atrium. Diagnosed by echocardiography. Treated by surgical excision of the tumour with the attached interatrial septum and patch closure of the created atrial septal defect.

Macroscopic specimen of an atrial myxoma. Note the irregular, heterogenous, and polypoid nature of the tumour.

Transoesophageal echocardiogram showing a left atrial myxoma prolapsing across and obstructing the mitral valve.

Atrial myxoma excision and patch repair.

THE PERICARDIUM PERICARDIAL EFFUSION Pericardial effusion is accumulation of fluid in the pericardial cavity. Aetiology: Malignant (75%) due to metastases (breast and lung cancers) or direct invasion from mediastinal tumors. benign (25%) due to infection, trauma, uremia, etc.. .

PERICARDIAL EFFUSION (cont.) Pathophysiology: The rapid fluid accumulation compresses the right atrium and ventricle →elevated central venous pressure, reduced diastolic filling and decrease in stroke volume → cardiac tamponade and cardiogenic shock.

PERICARDIAL EFFUSION (cont.) Clinical Picture: Pulsus paradoxus. Beck's triad (distended neck veins, muffled heart sounds, hypotension) are clinical findings in acute cardiac tamponade. Kussemel sign. Investigations: Echocardiography is diagnostic: It shows the pericardial fluid, compression of right atrium and ventricle and paradoxical septal motion.

PERICARDIAL EFFUSION (cont.) Treatment: 1. No hemodynamic compromise Treat underlying condition. Echocardiography guided pericardiocentesis. 2. Impending or acute tamponade Volume expansion to increase diastolic filling. Pericardiocentesis: Under local anesthesia using parasternal or subxiphoid route, guided by echocardiography. Drainage catheter may be positioned using the Seldinger technique.

Pericardiocentesis.

PERICARDIAL EFFUSION (cont.) 3. Surgical decompression: Indications: Clotted blood, trauma, purulent pericarditis, loculated effusions. Pericardial biopsy. Technique: Resection of a portion of the pericardium (creation of a pericardial window to drain pericardial fluid). Approach: Subxiphoid. Left anterior thoracotomy. VATS.

Left anterior thoracotomy for pericardial effusion.

CONSTRICTIVE PERICARDITIS The pericardium is fibrosed and thickened with obliteration of the pericardial space, producing uniform restriction of the diastolic filling of all heart chambers. Calcium deposition may contribute to stiffening of the pericardium. The commonest causes of pericarditis are: Idiopathic (50%). Tuberculosis (15%).

CONSTRICTIVE PERICARDITIS (cont.) The chest X-ray shows normal or mildly enlarged cardiac silhouette with calcification of the pericardium (50%). Echocardiography shows the thickened pericardium. CT and MRI are Superior in the assessment of pericardial thickness.

CONSTRICTIVE PERICARDITIS (cont.) The surgical treatment is Pericardiectomy: Complete resection of the pericardium through median sternotomy or left thoracotomy with or without cardiopulmonary bypass.

AORTA AORTIC DISSECTION Definition :  Tear in the intima of the aortic wall allows blood to enter and flow in a false channel .The true (aortic lumen) and false (plane of dissection) channels are separated by the dissecting membrane or flap that contains aortic media and intima.

AORTIC DISSECTION (cont.) Dissection can Weaken the outer wall of the aorta resulting in: rupture or formation of an aneurysm. Progress and occlude aortic branch vessels causing: myocardial infarction, stroke, kidney failure, bowel ischemia, paraplegia, limb ischemia. Disrupt aortic valve annulus resulting in: valvular insufficiency and cardiac failure.

AORTIC DISSECTION (cont.) Classification: Type A: Proximal dissection, involving the ascending aorta. Type B: Distal dissection, beyond left subclavian artery, involving descending thoracic aorta.

Stanford classification of aortic dissection (The left type A and the right type B).

AORTIC DISSECTION (cont.) Staging:  Acute: First 2 weeks. Subacute: First 2 months. Chronic: After the second month. Diagnosis: is based on High index of suspicion. The 5 P's: Pain, pallor, pulselessness, paraesthesia and paralysis. The Pain: is severe, in the chest (front, back or both), its location indicates the portion of the aorta involved in the dissection. Changing location indicates that the dissection is progressing.

AORTIC DISSECTION (cont.) Investigations CXR shows a broad mediastinum. Echocardiography (Transthoracic, transesophageal), CT scan, MRI and Aortography. show the true (internal) and false (external) lumen, locate the intimal tear (Type A or B dissection) and patency of aortic branches.

AORTIC DISSECTION (cont.) Treatment: Mortality in acute dissection is 50% during the first 48 hours without treatment.  Type A : Immediate surgery . Tube graft replacement of the ascending aorta through a sternotomy. Involvement of the aortic valve annulus requires resuspension of aortic cusps or aortic valve replacement. The coronary ostia may need to be implanted into the tube graft (Bentall's operation).

AORTIC DISSECTION (cont.) Type B: Stabilized medically and may not require immediate surgery. Sedation. Analgesia. Lower blood pressure to as low as 90-100 mm Hg with vasodilators as I.V. sodium nitroprusside. Slow the pulse and make the heart beat with less force with propranolol (- adrenergic blocker) or verapamil (calcium blocker). If not stabilized medically: Surgery with excision and tube graft replacement of the upper thoracic aorta through a left thoracotomy.

Aortic Aneurysm  It is an area of bulging in the wall of the aorta, weakened by atherosclerosis, degenerative disease as Marfan syndrome, syphilis or trauma. Types: saccular or diffuse. The danger of an aneurysm is that it may rupture. It is diagnosed with CXR, echocardiography, M.R.I., C.T. scan and Aortography.

Complications of Co A repair Aneurysm formation 20 years after patch aortoplasty.

AORTIC ANEURYSM

AORTIC ANEURYSM (cont.) The surgical treatment involves replacement with a Dacron tube graft when the diameter is over 5 to 6 cm depending on the location and rate of recent growth and onset of chest pain. Aneurysm of aortic arch: Replacement and establishment of new connections to arch branches.

AORTIC ANEURYSM (cont.) Aneurysm of the aortic root and sinuses of Valsalva with annuloaortic ectasia producing aortic regurge: Replacement with a valved tube graft and implantation of the coronary ostia into the graft (Bentall's operation). Aneurysm of the distal aortic arch and descending aorta: Replaced with tube graft through left thoracotomy. Endovascular Stenting.