Unusual treatment of postoperative bleeding after cardiac surgery

doi:10.4236/wjcd.2013.35058

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World Journal of Cardiovascular Diseases, 2013, 3, 377-379 WJCD

http://dx.doi.org/10.4236/wjcd.2013.35058 Published Online August 2013 (http://www.scirp.org/journal/wjcd/)

Unusual treatment of postoperative bleeding

after cardiac surgery

José Rubio-Alvarez1*, Juan Sierra-Quiroga1, Belén Adrio-Nazar1, Laura Reija López1,

Ángela Granda Bauza1, Carola Rubio Taboada2, Jose Manuel Martinez-Cereijo1

1Department of Cardiac Surgery, Universitary Hospital Santiago de Compostela, Santiago, Spain

2Department of Vascular Surgery, Universitary Hospital of Elche, Alicante, Spain

Email: *[email protected]

Received 15 June 2013; revised 20 July 2013; accepted 1 August 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

A young patient was presented to the emergency de-

partment with chest pain and palpitations. A tran-

sthoracic echocardiogram showed a right atrial mass.

Coronary angiography showed a right coronary ar-

tery with collateral circulation to a large mass. The

tumor could only be partially resected and the patient

experienced persistent postoperative bleeding. We

performed a new right coronary artery angiography

which showed an important free extravasation of

contrast into the pericardium through the collateral

circulation. Using covered stents, the bleeding was

controlled. The pathological examination performed

later revealed a primary cardiac angiosarcoma. After

asympto m-free survival of 14 month s the patien t pre-

sented bone metastases.

Keywords: Angiosarcoma; Coronary Stenting;

Postoperative Bleeding

1. INTRODUCTION

Primary cardiac malignant tumors are very uncommon

and about 75% are sarcomas [1]. Although rare, angio-

sarcomas are the most common primary malignant neo-

plasms of the heart and are very aggressive and locally

invasive. These tumors are highly vascularized and are

often are actively bleeding into the pericardium.

Since the introduction of percutaneous coronary inter-

vention (PCI) in 197 7, it is increasingly used not only in

simple coronary lesions, but also in complex coronary

anatomies. Coronary perforation is a rare but serious

complication of PCI with the occurrence of important

bleeding into the pericardium. However, this complica-

tion can be tackled successfully with covered stents [2].

We describe the case of a 50-year-old man with non-

metastatic primary right atrial (RA) angiosarcoma, who

underwent surgical excision of the tumor and recon-

struction of the RA with a bovine pericardial patch. The

tumour could only be partially resected and the patient

experienced persistent postoperative bleeding through

the collateral circulation from the right coronary artery,

which was controlled using covered stents. After a sym-

ptom-free survival of 12 months, the patient presented

bone metastases.

2. CASE REPORT

A 50-year-old previously healthy male visited emergency

service because of palpitations and left chest pain. A

chest X-ray showed enlargement of the RA border an d an

electrocardiogram showed normal sinus rhythm with a

heart rate of 87 beats per minute. A transthoracic echo-

cardiogram was performed and detected a RA mass (50 ×

45 mm) that had infiltrated the free wall of and protruded

into the RA (Figure 1(A)). Left ventricular function was

normal and there were no valvular abnormalities. For

further evaluation of the RA mass magnetic resonance

imaging was performed (Figure 1(B)). This exploration

also showed a large eccentric tumor (64 × 54 × 53 mm)

in the RA free wall, protruding into the right atrium. The

tumor extended into the right atrioventricular groove, but

did not involve the right ventricle, or the annulus of the

tricuspid valve. Coronary angiography showed a right

coronary artery with collateral circulation to a large mass.

Surgery was performed under standard extracorporeal

circulation with selective cannulation of both cava veins

and the ascending aorta. The RA was excised (Figure 2),

but the tumor could only be partially resected because it

extended into the free wall of the right ventricle and tri-

cuspid valve annulus. The RA was reconstructed using

bovine pericardium. After declamping massive bleeding

was present from the arterial sinuses of the cut edge of

*Corresponding a uthor.

OPEN ACCESS

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378

Figure 1. (A). Transthoracic echocardiography shows a large

mass (50 × 45 mm) that protrudes into the right atrium (*). (B)

Cardiovascular magnetic resonance imaging showed a large

eccentric and homogenous tumor (64 × 54 × 53 mm) in the

right atrial free wall, that protrudes into the right atrium (*).

Figure 2. Intraoperative photograph showing the angiosarcoma

in the right atrial wall.

the RA wall. Because it was not possible to control the

bleeding, we decided to close the chest and to perform a

right coronary angiography, which showed an important

free extravasation of contrast into the pericardium

throught the collateral circulation (Figure 3(A)). These

branches were tackled successfully using covered stents

(Figure 3(B)). Post-covered stent angiogram showed

complete cessation of contrast extravasation (Figure

3(C)). The total volume of postoperative bleeding was

630 cc. The postoperative course was uneventful and the

patient was discharged on the eighth postoperative day.

The histologic characteristics of the mass suggested car-

diac angiosarcoma: sinusoidal vascular channels full of

red blood cells and lined with spindle-shaped cells with

pleomorphic hyperchromatic nuclei. Immunohisto-che-

mical analysis was positive for vimentin, CD31, CD34,

actin, and focal factor VIII.

Figure 3. (A). Right coronary angiography showing an impor-

tant free extravasation of contrast into the pericardium through

the collateral circulation of the tumor. (B). Right coronary

stenting. (C). Right coronary angiography after coronary stent-

ing showing no extravasation of contrast into the pericardium.

After asymptom-free survival of 12 months the patient

presented with bone metastases.

3. DISCUSSION

Primary cardiac tumors are rare, with an incidence rate

ranging from 0.0017% to 0.033% [1] and the majority

are benign [3] with myxoma accounting for up to half of

cases. Twenty five percent of primary cardiac tumors are

malignant; of these, about 75% are sarcomas [1]. Angio-

sarcomas, although rare, are the most common primary

malignant neoplasms of the heart and tare highly aggres-

sive and locally invasive. They are highly vascularized

tumors and can cause active bleeding into the pericar-

dium. The angiosarcoma is seen more often in males than

in females and is usually presented between the third and

fifth decade of life [1]. Two thirds of angiosarcomas are

located on the right side of the heart, especially the

atrium and these tend to be presented with chest pain,

dysnea, pericardial effusion and arrhythmias. Cardiac

angiosar- comas can also remain asymptomatic until they

metasta- size.

Surgical excision is the main treatment of angiosar-

coma, but complete resection is difficult and the progno-

sis of primary cardiac angiosarcoma is poor, usually

having a short and fatal course. The mean survival of

these patients is 9 - 12 months following diagnosis. Ra-

diotherapy or chemotherapy before or after the operation

may reduce the rate of recurrence and metastasis [4].

Optimal imaging studies must precede surgical resec-

tion. However, these studies, like in our case, do not pro-

vide the exact extent of the tumor, and the surgeon must

keep in mind that angiosarcoma can infiltrate the tissue

surrounding the tumor.

These tumors are highly vascularized and can cause

J. Rubio-Alvarez et al. / World Journal of Cardiovascular Diseases 3 (2013) 377-379

379

active bleeding into the pericardium. In our case, the pre-

operative coronary angiography showed an atrial mass

with a vascular supply from the right coronary artery.

When we removed the clamp, massive bleeding was

presented from the arterial sinuses of the cut edge of the

RA wall. Because it was not possible to control the

bleeding, we decided to close the chest and perform a

right coronary angiography which revealed an important

free extravasation of contrast into the pericardium

through the collateral circulation. These branches were

tackled successfully with covered stents. The post-cove-

red stent angiogram showed complete cessation of con-

trast extravasation.

PCI is widely utilized in the treatment of symptomatic

coronary artery disease. Coronary perforation is a rare

complication of PCI, but covered stents effectively seal

coronary perforations when this occurs, especially when

the perforation involv es the proximal or mid-seg ments of

the artery where delivery of these devices is relatively

easy. Briguori, et al. [5] reported a 91% successful rate

of closure of Types I and II perforations with PTFE-cov-

ered stents and a significantly lower incidence of cardiac

tamponade or need for emergency surgery. In our case,

the use of covered stents was the solution for postopera-

tive bleeding.

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