[HSF] Curious mitral lesion

[psimha]

Did it look something like this (a blood cyst ?) These can at times 
calcify too.
Prasanna
Mark Levinson wrote:
>
> I was asked to see a 50 yo diabetic woman who presented to the 
> hospital with an acute CVA (hemiparesis, expressive aphasia).  Workup
> was entirely normal except for a round sessile mass in the posterior 
> left atrium, about 7 or 8 mm diameter seen in multiple views, presumed 
> to be a myxoma.
> The mass did not move much, did not prolapse through the mitral valve, 
> and appeared solid by echo criteria.    Unlike most myxomas,
> it was appeared to be located near annular portion of P2...
>
> I operated thinking this was a myxoma, just in an atypical location.   
> However, when I opened the atrium, it was normal !!   Empty!   Nada!
> I inspected the orifices of each pulmonary vein, and inverted the left 
> atrial appendage.    No tumor !    I looked into the LV cavity
> (transvalvar) and did not see anything.    There was no stalk-like or 
> sessile lesion, and importantly, normal endocardium throughout
> with no stain or color change to indicate something might have once 
> been there, and then dislodged.
>
> I was puzzled, and somewhat embarrased to close this case and be told 
> "its still there" on postop echo, so I ran my finger along
>  the left atrial tissue and mitral apparatus....and I felt a soft lump 
> under the posterior mitral leaflet.    There was no question on palpation
> that this was the lesion seen on echo because it was in the exact 
> location (behind the attachment point of P2).
>
> The endocardium was slightly whiter, or more pale, in this location, 
> and once I had retraction sutures in place, I could now see a bulge
> appearing to come from under the endocardium and lifting the 
> endocardium, forming a mass that protruded slightly into the cavity.
> However, it was soft, not hard.   I wondered if this was a lipoma, as 
> can be seen in the septum, but the echo would suggest something
> more dense.     And I had to try to explain her stroke.
>
> So, I incised the endocardium to take a look at the mass, and I was 
> greeted with a liquified white cheezy material similar to what you see
> coming from an old caseous granuloma.    For a brief moment, I thought 
> I has just opened a sebaceous cyst!    About 1 or 2 cc of this liquified
> material was expressed.   It was not purulent in my opinion, but
> reminded me of the "milk of calcium" I had heard about in my training 
> years back.   I scooped it up and sent for gram stain (negative).   I 
> cleaned
> the cavity out with swabs and suction.   Visually, the interior of the 
> cavity demonstrated muscle fibers and spicules of calcium.    The cavity
> clearly traveled into the subvalvar myocardium.     There was no other 
> evidence of SBE, so I did not see an indication to resect the P2, and try
> to reconstruct this area.   I was concerned that I would nail the Cx, 
> coronary sinus, or induce a posterior AV separation if I ventured too 
> far.
>
> So, excised some tissue for biopsy, then packed the cavity with "milk 
> of Vancomycin" (home-made) and closed it with interrupted Prolenes,
> ligated the LA appendage, and closed. She has done very well, with all 
> cultures negative and a normal post-operative course.
>
> However, I can't explain what  I saw.    The pathologists have 
> indicated this is probably a granuloma, but it is not a very 
> satisfying diagnosis.
>
> What caused her stroke?    Could this liquified material have escaped 
> at some point and embolized?
>
> Has anyone seen anything like this before.
>
> I apologize that my still camera photos are not suitable...I do have 
> movies but can't seem to get them loaded on my Mac for editing....sorrry.
>
> Thanks,
>
> Mark
>
>
> Mark M. Levinson, MD
> Founder, Editor-in-Chief,
> The Heart Surgery Forum
> WWW: <http://www.hsforum.com>
> Email: <mmLevinson at hsforum.com>
>
>
>
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