A large cardiac tumor obstructing left ventricular inflow

Excerpt

A 62-year-old man was admitted to the department of cardiovascular surgery post ST-elevation myocardial infarction for a scheduled coronary artery bypass grafting (CABG) due to severe coronary artery disease. A tumor in the left atrium (LA) was incidentally seen on preoperative transthoracic echocardiography and confirmed by cardiac computer tomography (35 × 70 mm) (Fig. 1a–d). Despite its large size, the tumor did not obstruct left ventricular inflow via the mitral valve (MV) at rest, the left ventricle (LV) appeared normovolemic (Fig. 1b). However, after induction of general anesthesia hemodynamics were severely compromised. Transesophageal echocardiography now revealed an obstruction of the LV inflow by the tumor, which almost completely filled out the LA resulting in LV hypovolemia (Fig. 2a–d) (Supplementary videos a–d). By increasing preload (1,000 ml fluid) and afterload (norepinephrine) the obstruction resolved owing to improved LA filling increasing the distance between the tumor and LV inflow/MV. Cardiopulmonary bypass, CABG, and tumor resection proceeded uneventfully with insignificant doses of catecholamines. Pathological explorations were consistent with hemorrhaged cardiac tissue, subendocardial fibrosis, and coagulum. In conclusion, a preoperative non-obstructive cardiac tumor can become obstructive during general anesthesia as a result of altered cardiovascular loading conditions. Immediate echocardiographic evaluation is recommended in the case of hemodynamic instability.

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