Cardiac tumors are rare. During resection of a tumor, there is always a risk of cardiac perforation; therefore, resection is often performed using cardiopulmonary bypass. We present the case of a pediatric patient undergoing cardiac tumor resection without cardiopulmonary bypass and discuss the utility of intraoperative transesophageal echocardiography (TEE) and epicardial echocardiography (EE) for surgical planning and intraoperative management.
The patient was a 6-yr-old girl (115 cm, 19 kg). Arterial blood pressure was 110/70 mm Hg, and heart rate was 78 bpm. Nothing noteworthy was found in her medical history. On physical examination, the patient was well developed and looked healthy. An abnormality (complete left bundle branch block) on her electrocardiogram was noticed during a medical examination. Transthoracic echocardiography and computed tomography revealed a large mass (12 x 8 x 7 cm) compressing the left ventricle and extending from the aortic arch to the diaphragm. The origin of the tumor was identified as the heart because the blood flowed from the first and second diagonal branches of the left anterior descending coronary artery to the tumor, as confirmed by cardiac catheterization. The definitive diagnosis, made with an open biopsy, identified the tumor as a lipoma (lipomatous infiltration of the heart). Partial resection of the mass was scheduled to decompress the left lung, pulmonary artery, and left ventricle.
On the day of surgery, the patient was premedicated with scopolamine 0.15 mg and midazolam 1.5 mg administered IM 30 min before arrival in the operating room. Anesthesia was induced with sevoflurane, oxygen, and nitrous oxide, and tracheal intubation was facilitated by the IV administration of vecuronium 0.15 mg/kg. A right radial artery was cannulated for continuous monitoring of arterial pressures, and a central venous catheter was inserted via the right internal jugular vein. A 6.8-mm TEE probe (5 MHz; Aloka, Tokyo, Japan) was then inserted into the esophagus and attached to a color Doppler imaging system (Aloka). Anesthesia was then maintained with nitrous oxide, oxygen, sevoflurane, and a continuous IV infusion of fentanyl. Muscle relaxation was obtained with vecuronium. The surgery was performed after preparation for cardiopulmonary bypass. TEE clearly revealed that the tumor (Figure 1) was huge and that it compressed the left ventricle and included the posterior leaflet of the mitral valve. However, it was difficult to determine the boundaries of the tumor based on the TEE alone because the tumor was a hard and high-density mass, and it was difficult to confirm accurately its depth from the acoustic shadow. Therefore, epicardial imaging with a 5-MHz precordial probe (Aloka) was also performed (Figure 2), although this procedure required interruption of the surgery. Approximately one third of the tumor was resected successfully under the guidance of both TEE and EE. Decompression of the left ventricle was accomplished without cardiopulmonary bypass. The postoperative course was uneventful, and the patient was discharged from the hospital on the 26th postoperative day.
In this report, we describe the intraoperative management of an asymptomatic 6-yr-old girl undergoing resection of a cardiac tumor with the aid of TEE and EE. It has been reported that intracardiac masses, including tumors and thrombi, are good applications of TEE. TEE has been used to examine intracardiac tumors and has provided superior visualization of the tumor attachment sites because of good resolution of the posterior cardiac structures [1-4]. TEE can provide useful information about the origin and extension of a tumor. Recently, TEE has become a routine monitoring procedure during cardiovascular surgery, and there are reports regarding TEE monitoring used during the resection of cardiac tumors [3,4]. However, primary cardiac tumors are extremely rare, with a reported incidence ranging from 0.0017% to 0.28% in autopsy studies  and from 0.2% to 2% in other studies . Primary tumors of the heart in infants are especially rare. There are few reports about lipomas, which are benign connective tissue tumors. Estevez et al.  reported a tumor similar to the one we describe in a 19-yr-old young adult. Lewis et al.  reported a case of resection of a papillary tumor of the aortic valve using EE monitoring.
EE has also been used for monitoring during cardiovascular surgery, but its use decreased rapidly with the development of TEE. The limited intraoperative period during which EE can be used is a clear disadvantage. In addition, the scan planes are difficult to standardize, and this technique cannot be used for some patients because of induced arrhythmia and hypotension. However, EE has the advantage of high resolution and multiple scan planes and is more effective than TEE in delineating the view of the left ventricular outflow. In contrast, TEE can be used for monitoring during the entire operative period, and sterile conditions are not affected because it is a noncontact procedure [8,9].
We used TEE to determine the volume of the tumor to be resected. However, it was difficult to confirm the boundaries of the tumor using only TEE; therefore, we also used EE. The combined use of intraoperative TEE and EE provided the necessary information. To our knowledge, there are no reports regarding intraoperative management of a pediatric patient undergoing resection for a cardiac tumor using both TEE and EE. We achieved good results using both TEE and EE in a complementary fashion, thus compensating for the disadvantages of each techniques. Therefore, the combined use of TEE and EE should be considered under such circumstances.
In summary, we performed resection of a large benign cardiac tumor and found that the combination of intraoperative TEE and EE yielded important clinical information and enhanced the operative planning and intraoperative management.
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