PMC3599281_01
A. Computed tomography imaging reconstruction of the heart. The tumor is showed. The collateral vessel (white arrow) from the circumflex artery (CxA) is observed. B. 18-F DOPA PET showed a 16 x 25 x 36 mm extracardiac mass protruding within the LA. Presence of metabolic activity was detected. C. Computed tomography (axial view) showed the presence of the large mass (red arrow). D. Coronary angiography. The coronary blood supply of the superior aspect of the paraganglioma (T) emerged from a large collateral vessel (white arrow) from the right coronary artery (RCA). E. Coronary angiography. Proximal and distal collaterals from CxA were the feeding vessels (white arrow) of the inferior aspect of the tumor (T).
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F1
Transesophageal echocardiography (TOE) and TC imaging of the heart showed the large mass (40 x 20 mm), extrinsic to the heart, on the posterior wall of the left atrium (LA) (Figure 1A-C). Coronary angiography and aortography were performed: the tumor received dual blood supply from both right and left coronary arteries (Figure 1D-E).
A. Peripheral perfusion through right femoral artery and vein. B. Superior vein cavae (SVC) drainage through Pacifico cannula.C. The large collateral vessel from the RCA was dissected and ligated. RA: Right atrium. Ao: Aorta. D. The two collateral vessels from CxA (white arrow) were also ligated for an optimal control of bleeding during the excision of the tumor. CS: Coronary sinus. LPVs: Left pulmonary veins.
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F2
As part of our initial surgical planning, cardiopulmonary bypass (CPB) was started through right femoral artery and venous cannulation (right femoral vein and superior vein cava) (Figure 2A-B) because of surgical excision could be technically difficult by the position of the tumor. Direct ligation of feeding vessels was performed for control of bleeding: the collaterals vessels from the right coronary artery (RCA) and circumflex artery (CxA) were ligated (Figure 2C-D).
A. Surgeon's view. Superior aspect of the tumor (black arrow) is showed. Neovascularization of the smooth surface is observed. B. Endocardium of the LA was exposed (black arrow) during surgical excision (suspended heart). C. Surgeon's view. Dissection of the superior aspect of the tumor (T). D. Paraganglioma (T) after totally excision from the LA. IVC: Inferior vein cava. LIPV: Left inferior vein cava.
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F3
Following excision of the superior pericardial reflection (Figure 3A), the left posterior atrial wall was exposed and the superior aspect of the tumor was excised. There was no a plane of cleavage between the LA and the tumor, and atrial myocardium was also removed (Figure 3B-C). The division of great vessels and LA was not necessary to access the tumor and it was completely excised en bloc (Figure 3D).
A. LA after removal of the tumor. The operative photograph shows the distal collateral vessel (white arrow) from CxA (after ligation). Endocardium of the LA remained in situ. LAA: Left atrial appendage. OS: Oblique sinus. B. Bovine pericardial patch (black arrow) was used for left atrial reconstruction. The suture was started from the left atrial roof. C-D. Pericardial patch was placed on the posterior wall of the LA using a polypropylene running suture.
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F4
Adequate disease-free margins were achieved and the denuded LA was reconstructed using a bovine pericardial patch (Figures 4A-D and 5A) and it was reinforced with surgical sealant.
A. Posterior LA after pericardial replacement. B. Macroscopic examination (6 x 3 x 1.5 cm fragment). A well-demarcated homogeneous, smooth surfaced and highly vascularized tumor (2.8 x 2.5 x 1.5 cm) was found, with clear surgical margins. C. Histological examination. Haematoxylin and eosin staining (H & E, 40x magnification) showing the "zellballen" packeting of cells, without atypia, surrounded by capillary network (blue arrow). D. Immunohistochemical analysis (40x magnification) revealed the specific neuroendocrine markers (chromogranin and synaptophysin, C & S). S-100 protein staining technique (100x magnification) revealed the sustentacular cell network (black arrow).
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F5
Adequate disease-free margins were achieved and the denuded LA was reconstructed using a bovine pericardial patch (Figures 4A-D and 5A) and it was reinforced with surgical sealant. Histological examination confirmed the paraganglioma and malignant changes were not found (Figure 5B-C). Chromogranin and synaptophysin were positive at immunohistochemistry, and sustentacular cells were positive for S-100 protein staining (Figure 5D).