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Asian Cardiovasc Thorac Ann 2000;8:278-279
© 2000 Asia Publishing EXchange Pte Ltd

CASE STUDY

Giant Blood Cyst of the Mitral Valve

Sanjeev Sharma, MD, Richard Strauss, MD, Jeffrey S Swanson, MD

Albert Starr Academic Center
Providence St. Vincents Medical Center
Portland, Oregon, USA
For reprint information contact: Sanjeev Sharma, MD Tel: 1 520 626 6339 Fax: 1 520 626 4042 email: tazsharma{at}aol.com Section of Cardiovascular and Thoracic Surgery, The University of Arizona Health Sciences Center, 1501 N. Campbell Ave, Tucson, AZ 85724-5071, USA.

   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
A 68-year-old man underwent coronary angiography for postinfarction angina, which revealed right coronary artery stenosis and a mass in the left ventricle. Transesophageal echocardiography showed a large blood cyst originating from the anterior papillary muscle of the mitral valve. Coronary artery bypass grafting was performed and the cyst was successfully excised.


   Introduction
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 Abstract
 Introduction
Case Report
 Discussion
 References
 
Blood cysts are congenital cysts found on the endocardium, particularly along the closing lines of the heart valves.1 They are benign cardiovascular tumors and are incidental autopsy findings on cardiac valves in approximately 50% of infants under 2 months of age.2 Blood cysts are rare after 2 years of age. When found in adults, they can be large and may result in severe left ventricular outflow tract obstruction.3 Myxomas should be considered in the differential diagnosis of intracardiac masses.1


   Case Report
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 Abstract
 Introduction
 Case Report
Discussion
 References
 
An active 68-year-old man presented with substernal chest pain and was found to have a subendocardial myocardial infarction. He underwent coronary angiography for postinfarction angina, which revealed greater than 70% stenosis of the right coronary artery. Ventriculography demonstrated well-preserved left ventricular function with an ejection fraction of 76% and a mobile round intra-cavitary mass in the left ventricle associated with moderate mitral regurgitation (Figure 1Go). Transesophageal echo-cardiography revealed a 2-cm multiloculated cystic mass affixed to the anterior papillary muscle of the mitral valve and associated with moderate mitral regurgitation (Figure 2Go). The left atrium and left ventricle were of normal size and function, the mitral valve leaflets were thin and pliable with good coaptation, except centrally.



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  		Figure 1. Left ventriculogram demonstrating a large round intracavitary mass associated with moderate mitral regurgitation.

 


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  		Figure 2. Transesophageal echocardiogram showing a 2-cm cystic mass affixed to the anterior papillary muscle of the mitral valve. LA = left atrium, LV = left ventricle, MV = mitral valve.

 
The patient underwent a median sternotomy for excision of the intracavitary mass and anastomosis of a reversed saphenous vein graft to the right coronary artery. Cardio-pulmonary bypass was established using aortic and single two-stage venous cannulation. The patient was cooled to 30°C and bypass grafting on the right coronary artery was performed using an intermittent crossclamp technique. The temperature was then lowered to 28°C, the aorta was again crossclamped, and cold hyperkalemic blood cardioplegic solution was administered through the aortic root. A low transverse aortotomy was made, the aortic valve leaflets were retracted, and the cystic mass was excised from the anterior papillary muscle. No other valve pathology was identified. Intraoperative transesophageal echocardiography after separation from cardiopulmonary bypass showed only trivial residual mitral regurgitation. The cyst was a smooth round multiloculated 2-cm fluid-filled mass adherent to the anterior papillary muscle of the mitral valve. On microscopic examination, the mass was nonmalignant and lined with endothelial cells (Figure 3Go).



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  		Figure 3. Histology of the blood cyst. Hematoxylin and eosin stain revealed an endothelial-lined cystic mass (original magnification x100).

 

   Discussion
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 Abstract
 Introduction
 Case Report
 Discussion
References
 
Blood cysts involving heart valves were first reported by Elsässer4 in 1844. These cysts are usually blood-filled nodules measuring 1 to 2 mm, which are associated most commonly with the atrioventricular valves but they have been reported on the semilunar valves.1,2,5,6 Three theories have been proposed for the origin of blood cysts: one suggests that the cysts are formed during valve development by blood being trapped in crevices that seal off; another theory proposes that these cysts are the result of microscopic invaginations of the valve cusps; a third theory postulates that primitive pericardium abnormally migrates into the myocardium to form fibrous structures.7 Whatever the cause may be, these cysts are benign masses and are most commonly seen in infants.2 However, blood cysts can be large and may cause obstructive or regurgitant symptoms depending on their location.3,6 Severe complications such as symptoms of cardiac failure and systemic emboli have been noted.3 Transesophageal echocardiography is the diagnostic modality of choice for cardiac masses.8 It allows better visualization of intracardiac structures and the great vessels than transthoracic echocardiography. Furthermore, transesophageal echocardiography provides clearer in-formation regarding intracardiac chamber size and function as well as valvular function. The transaortic approach used in this patient provided excellent visualization of the cystic mass and the anterior papillary muscle of the mitral valve. Excision of the giant blood cyst was simple and restored mitral valve competence.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Burke A, Virmani R. Tumors of the heart and great vessels. Atlas of tumor pathology. Third series, fascicle 16. Washington: Armed Forces Institute of Pathology, 1996:79.

  2. Zimmerman KG, Paplanus SH, Dong S, Nagle RB. Congenital blood cysts of the heart valves. Hum Pathol 1983;14:699–703.[Medline]

  3. Firmin RK, Arnold IR, Hubner PJB. Blood filled cyst of the papillary muscle of the mitral valve producing severe left ventricular outflow tract obstruction. Br Heart J 1990;63:132–3.[Abstract/Free Full Text]

  4. Elsässer C. Bericht über die Ereignisse in der Gebäranstalt des Catherinen. Hospitals im Jahre 1844. Med Correspondenzblatt 1844;14:297.

  5. Pasaoglu I, Dogan R, Demircin M, Bozer AY. Blood cyst of the pulmonary valve causing pulmonic valve stenosis. Am J Cardiol 1993;72:493–4.[Medline]

  6. DeGroff C, Silberbach M, Sahn DJ, Droukas P. Giant blood cyst of the aortic valve. J Am Soc Echocardiogr 1995;8:543–5.[Medline]

  7. Roberts PF, Serra AJ, McNicholas KW, Shapira N, Lemole GM. Atrial blood cyst: a rare finding. Ann Thorac Surg 1996;62:880–2.[Abstract/Free Full Text]

  8. Reeder GS, Khandheria BK, Seward JB. Tajik AJ. Transesophageal echocardiography and cardiac masses. Mayo Clin Proc 1991;66:1101–9.[Medline]





This Article
Right arrow Abstract Freely available
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Right arrow Author home page(s):
Sanjeev Sharma
Jeffrey S Swanson
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Right arrow Articles by Sharma, S.
Right arrow Articles by Swanson, J. S
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Right arrow Articles by Sharma, S.
Right arrow Articles by Swanson, J. S

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