a 43-year - old woman diagnosed with intravenous leiomyomatosis at another hospital was transferred to our hospital . she had suffered from palpitation , dizziness , dyspnea , and chest pain for two weeks prior to admission into another hospital , and had experienced syncope three times on the day of admission to our hospital . no cardiac murmur was noted , and laboratory findings were unremarkable with the exception of anemia ( hemoglobin : 9.7 g / l ) . cardiac and pelvic magnetic resonance imaging ( mri ) taken at the previous hospital revealed multiple low attenuation masses in the uterus , involving both ovaries , the left gonadal vein , the left internal iliac vein , and the left renal vein , which extended into the inferior vena cava ( ivc ) , and to the right atrium ( ra ) ( fig . 1 ) . a trans - thoracic echocardiogram revealed a 4.81.8-cm hypermobile and echogenic mass in the ra connected to the mass in the ivc . emergency one - stage operation was planned with a gynecologist , and upon being transferred to the operation room , the patient had a sudden onset of dyspnea and unstable blood pressure . rapid endotracheal intubation was performed to maintain blood oxygen saturation . in transesophageal echocardiography ( tee ) , the echogenic mass in the ra and ivc was not seen . we suggested that the mass detached from the ra and migrated to the right ventricle or the pulmonary artery . we discovered an echogenic linear mass in the pulmonary artery between the arterial bifurcation and both main pulmonary arterial branches ( fig . trans - abdominal hysterectomy and left salphingo - oophorectomy were performed through median laparotomy , and the mass in the left gonadal and internal iliac veins was completely removed ( fig . another mass in the pulmonary artery was also removed under conventional cardiopulmonary bypass without circulatory arrest ( fig . the ra was opened to confirm that there was no remnant mass in the ra and the ivc . the patient 's postoperative course was uneventful , and she has received follow - up care for two years without any evidence of tumor recurrence . intravenous leiomyomatosis is a benign intravascular proliferation of smooth muscle cells originating from the intrauterine venules and reaching the right heart . the uncommon benign tumor usually arises from either the uterine venous wall or uterine leiomyoma , and although it is histologically benign , it can cause fatal cardiovascular complications such as cardiac failure , pulmonary embolization , or sudden death . in previously reported cases describing intracardiac involvement , the tumor extended to the right atrium in 30% of cases , and to the right ventricle in 70% of cases . extension or embolization into the pulmonary artery or lung metastasis is a very rare complication constituting less than 5% of the reported cases . however , when it occurs , the course of the patient can be fatal , and urgent surgical correction is imperative . ariza and colleagues described the first successful two - stage removal of an intracaval mass , with delayed laparotomy after resection of the intracardiac portion of a tumor in 1982 . since then , a staged operation has been performed in many cases ( radical resections of intracavocardiac tumors and intrapelvic components in separate operations ) , but more recently , a one - stage approach by median sternotomy with cardiopulmonary bypass with or without hypothermic circulatory arrest , and a separate laparotomy has been performed successfully . the advantages of the one - stage resection include avoiding risks of tumor embolism , tumor progression , or hemodynamic complications in the interval between the two stages of two - staged operations . in addition , because both abdominal and thoracic cavities are opened , the tumor can be removed completely , and vascular reconstruction and bleeding control may be more easily performed . however , in hemodynamically unstable patients , the longer operative time may not be appropriate , and a two - stage operation may be beneficial . since incomplete resection of the tumor may causes recurrence , gathering detailed preoperative information regarding tumor localization , size , and extent by using abdominal ultrasound , echocardiogram , computed tomography , magnetic resonance imaging , and venography is required . transesophageal echocardiography should also be performed to detect possible changes in the location and size of the tumor , as occurred in this case . in conclusion , intracardiac leiomyomatosis should be considered in a female patient presenting with an extensive mass in the right side of the heart , and urgent surgical removal should be performed to avoid possible fatal complications , even if the patient is asymptomatic . as the tumor may move or detach from the central venous system even during operation , intraoperative tee
a 43-year - old woman was diagnosed with an intravenous leiomyomatosis at a previous hospital and transferred to our hospital to undergo surgical treatment . 
 emergency one - stage operation for coincidental removal of intra - abdominal , right atrial , and intravenous masses were planned . upon arriving at the operating room 
 , she suffered a sudden onset of severe dyspnea and showed hemodynamic instability . 
 intraoperative tee showed pulmonary embolization of a right atrial mass . 
 removal of the pulmonary artery mass and the intra - abdominal mass , and the cardiopulmonary bypass were performed without any complications .