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We report on the surgical resolution of a blood cyst in the right atrium with a minimally invasive approach through a mini video-assisted right anterolateral thoracotomy.
Blood cardiac cyst is rare entity usually found within the first 6 months of life, usually located in the atrioventricular valves, more frequently on the left side.
The diagnosis in adult patients and on the right side of the heart is infrequent. These cysts are aberrant embryologic remnants of the Chiari network that lead to the formation of a diverticulum adhered to the interatrial septum at the level of the inlet of the sinus venosus and the inferior vena cava. They are generally asymptomatic in adults but can cause valvular valve dysfunction, embolic stroke, and pulmonary embolism.
We present the case of a 48-year-old male patient with no medical history or cardiovascular risk factors who was under study for nonspecific chest pain. As part of the complementary studies, an echocardiogram was requested, which showed preserved ventricular function without valvular heart disease and a nonspecific thickening of the interatrial septum (Figure 1, A). The study was complemented with a multislice computed tomography angiography, which confirmed no evidence of coronary disease but revealed a round, solid, heterogeneous formation of 16 × 15 × 20 mm, with soft-tissue density with calcifications inside, that contacted the interatrial septum, the ostium of the sinus venosus, and the medial wall of the inferior vena cava (Figure 1, B). The study was extended with a cardiac magnetic resonance imaging, which showed, between the inlet of the inferior vena cava and the coronary sinus, a rounded 13 × 12-mm mass with clear edges, no pedicle, and nonmobile, hyperintense in T2, heterogeneous in T1. It was not canceled in sequence with fat saturation, hypointense in early enhancement sequence, and hypointense in late enhancement sequence (Figure 1, C). With the diagnosis of right atrial mass, surgical resolution was decided through a minimally invasive approach through a mini video-assisted right anterolateral thoracotomy with femoral venous and arterial cannulation (Figure 1, D).
Figure 1A, Echocardiographic image of nonspecific thickening of the interatrial septum. B, Cystic lesion with calcium densities inside adhered to the interatrial septum by computed tomography. C, Nuclear magnetic resonance image in T2 STIR (short inversion time inversion recovery) sequence. D, Minimally invasive approach by right anterolateral mini-thoracotomy.
The tumor was approached through a right atriotomy, where we encountered a violaceous cystic mass adhered to the sinus venosus (Figure 2, A). During the resection, the wall of the cyst was opened, revealing its blood content and 3 calcified structures inside it with the appearance of phleboliths (Figure 2, B, and Video 1). Extracorporeal circulation and clamping times were 64 and 27 minutes, respectively. The patient had an uneventful postoperative course and was discharged from the hospital on the sixth postoperative day. He returned to his regular activities at 14 days after discharge, with a cosmetic and functional result superior to conventional sternotomy (Figure 2, C).
Figure 2A, Intraoperative finding: purple cyst between the inferior vena cava and the sinus venosus. B, Phlebolith-like formations found inside the cyst. C, Scar from the minimally invasive approach by anterolateral minithoracotomy D, Microscopic analysis.
The pathologic study of the extracted piece describes a cystic-like formation with thickened walls made up of collagen tissue and surrounded by CD31+ endothelial cells. In its interior, hematic fibrin material and calcium deposits were observed. Findings were compatible with the diagnosis of hematic cyst (Figure 2, D).
Discussion
Cardiac blood cysts are a rare entity usually seen in infants, and their most frequent location is along the closure lines of the atrioventricular valves in 96% of the cases, less frequently in the aortic and pulmonary valves. These cysts can disappear spontaneously during childhood, so it is uncommon to find them in adult patients.
The origin of these heart cysts has not yet been elucidated, and several hypotheses have been proposed. Kantelip and colleagues postulated that blood cysts arise from heteroplastic changes in tissues originating from the primitive pericardial mesothelium, which is involved in the formation of the fibrous skeleton of the heart.
Diagnosis is usually through a finding in a routine study, and they are usually asymptomatic but may cause symptoms due to valvular valve dysfunction, embolic stroke, and pulmonary embolism. The minimally invasive approach by minithoracotomy offers an alternative to the conventional approach by sternotomy, avoiding all the complications related to it. Analogous to mitral surgery approaches, minimally invasive surgery reduces the rate of postoperative bleeding, the need for blood transfusions, and reduces the number of days of hospitalization both in the critical care unit and in total days of hospitalization.
published their series of 50 patients with cardiac masses comparing conventional sternotomy versus minimally invasive approach through a right minithoracotomy and found no significant differences between the 2 groups in terms of cardiopulmonary bypass time, aortic crossclamp time, postoperative intubation time, intensive care unit days, and length of the hospital stay. Patients with right anterolateral minithoracotomy had less postoperative chest drainage (536 ± 159 vs 773 ± 255 mL, P < .01) and transfusion rate (5.9% vs 33.3%, P = .033) than those who had sternotomy.
also compared both approaches for cardiac masses in 34 consecutive patients and concluded in their experience that minimally invasive atrial mass excisions can be accomplished reliably without compromising complete tumor resection and without significant increases in operative times or serious adverse events.
This article was reviewed and approved by Hospital Austral Scientific Board (Approval date: March 1, 2022). The patient provided written informed consent for the publication of the study data.
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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