Stanisław Ostrowski, Anna Marcinkiewicz, Anna Kośmider, Witold Pawłowski, Alicja Nowakowska, Ryszard Jaszewski Case report A 62-year-old woman with a diagnosed heart tumour and lymphadenopathy of the mediastinal lymph nodes was referred to the Cardiosurgery Clinic of the Medical University at Sterlinga Street 1/3 from the 2nd Department and Clinic of Cardio- logy UM in Lodz. Two weeks earlier the patient had been admitted to the pulmonary department with symptoms of generalized malaise and a cough, and with a case history of diabetes mellitus type II, arterial hypertension, spine degenerative disease, cholecystolithiasis, past hysterectomy (at the age 48 years) and nodular goitre which was diagnosed histopathologically 3 months earlier the same year. A benign tumour of the right lobe was evident. Physical examination revealed no significant abnormalities. Heart auscultation revealed a systolic murmur. A nodule of the right thyroid lobe was also found. Further examination revealed linear lesions at the base of both lungs, enlarged mediastinal lymph nodes, not grouped in packages, and a nodular structure in the left part of the heart. The patient was consulted cardiosurgically and admission to the clinic was made after urgent cardiological diagnostics with special emphasis on transthoracic echocardiography (TTE). During the stay in the Clinic of Cardiology, a basic check-up panel was performed, preparing the patient for the planned urgent operation – ECG and coronarography were negative. The cardiac tumour was analysed specifically and verified by transo- esophageal echocardiography (TEE). This established the presence of a gelatinous tissue, thickness 10 mm, with a villous surface within the interatrial septum, partially in the left atrium wall. Also located was an additional filamentous structure with length of 14 mm, at the anterior leaflet of the mitral valve from the left atrium site, and a pedunculated, mobile structure, size 4 cm × 2 cm, originating probably from the base of the anterior leaflet. The entire valvular structure was thickened. Moderate IM and mild IT were coexisting. The mass was collapsing into the left ventricular outflow, resulting in blood flow acceleration to 3.5 m/s and a maximum gradient through the aortic valve of around 50 mmHg. A slight effusion was discovered in the pericardial space. With regard to diagnosed lymphadenopathy, after pulmonary consultation, lymph node excision during cardiosurgical operation was recommended. The patient was admitted to the Cardiosurgical Clinic with the symptoms of generalised malaise, dizziness and easy fatigue on exertion. For some time the patient had also complained of a pain in the left hip during walking. The stage of euthyreosis was achieved. The removal of the left atrium and left ventricle tumour was carried out with the extracorporeal circulation, in moderate hypothermia (32°C). Protection of the heart was achieved by a cold crystalloid cardioplegin solution, applied to the aortic bulb. The operation lasted 2 h and 10 min. The total time of the extracorporeal circulation was 62 min, with the aorta cross-clamped for 48 min. Intraoperatively, the tumour mass was occupying the left atrium, blocking the mitral valve and pulmonary veins ostia. The neoplastic infiltration enclosed the anterior leaflet with a continuation in the left ventricle. The largest possible tumour mass was removed from the left ventricle and left atrium; the pulmonary veins ostia and the mitral valve were also released. Two nodules connected with the anterior leaflet of the mitral valve, which were collapsing to the left ventricle, were also excised. Anterior leaflet plasty was conducted. The enlarged mediastinal lymph nodes were taken for further examination. The tumour structure and localization did not allow for a radical excision, especially in the left ventricle. A decision not to implant the prosthesis instead of the mitral valve was made. The removed biological material was sent for histopathological examination. The postoperative period was uneventful. In the postoperative control echocardiogram a detected recurrence (9th day from the operation) was a mobile, nodular structure, measuring 3.2 cm × 1.8 cm, impeding the blood outflow from the left ventricle and filamentous streak, length 0.9 cm, leading from the middle segment of the anterior mitral leaflet. The haemodynamic parameters were as follows: • for the aortic valve, maximum gradient 53.5 mmHg, maximum blood flow 3.65 m/s, • for the mitral valve, respectively 23 mmHg and 2.4 m/s. In addition, in the TTE exam mild IA, moderate IM and moderate IT were recorded and enlarge- ment of all heart chambers was noted: • left atrium 6.3 cm × 5.3 cm, • left ventricle at systole 4 cm and at diastole 5.9 cm, • right atrium 6.2 cm × 4.1 cm, • right ventricle 2.7 cm. The systolic function of the heart muscle was evaluated as good with the ejection fraction 55%, however, it is claimed to be overrated by the mitral insufficiency. A slight pericardial effusion was present. Before surgery, during the additional examination, there was recorded an increased level of inflammatory markers, leukocytosis, C-reactive protein (CRP) and fibrinogen. In the postoperative period there was a significant increase in CRP and with blood cells (WBC) without clinical signs of inflammation. During hospitalization, their levels had gradually decreased, but the value of CRP was eventually not normalized. In the histopathological assessment, including the immunochemistry, the neoplasm was recognized as liposarcoma mostly 910 Arch Med Sci 5, October / 2011