Letter to the Editor A rare case of right atrium mass involving the right coronary artery and the tricuspid annulus Fabrizio Sansone ⁎, Edoardo Zingarelli, Guglielmo Mario Actis Dato, Roberto Flocco, Giuseppe Punta, Francesco Parisi, Pier Giuseppe Forsennati, Gian Luca Bardi, Stefano del Ponte, Riccardo Casabona Division of Cardiac Surgery, Mauriziano Umberto I Hospital, L.go Turati, 62, 10135, Turin, Italy article info Available online 8 October 2010 Keywords: Cardiac tumor Right atrial mass Right coronary artery Tricuspid annulus Dear Editor, We read with great interest the paper of Maraj et al. [1] dis- cussing about the history of the primary cardiac tumors: we agree with the Authors that the aim of the clinicians must be precocious diagnosis even if clinical presentation would be heterogeneous. Moreover, primary cardiac tumors are very rare and in many cases patients may be asymptomatic so that incidental diagnosis is quite common. We present the case of a 28-year-old male referred for dyspnea and palpitations that appeared about two months before. Clinical management by general practitioners was not clear and he un- derwent cardiac assessment only two months later. The trans- thoracic echocardiography revealed the presence of a large cardiac primitive mass. The magnetic resonance imaging (MRI) study showed an 8×6.5×7 cm tumor arising from the free wall of the right atrium, involving the proximal and the medium tract of a patent right coronary artery (Fig. 1A–B). Tricuspid annulus, right ventricle and superior vena cava were compressed (Fig. 1A–B). Ascending aorta was very close to the lesion (Fig. 2A–B) and MRI showed a 15 mm metastasis in the left lung (Fig. 2A–B). Intravenous administration of gadolinium enhanced multiple necrosis areas suggestive for a primary cardiac sarcoma. Considering the unfavour- able location and the presence of metastasis, surgical excision was not considered and chemotherapy (using bleomicin) was adminis- tered such as palliative therapy. Recurrent pericardial serum- haematic effusion required multiple pericardiocentesis and blood International Journal of Cardiology 152 (2011) e4–e5 ⁎ Corresponding author. Tel.: +39 0115082812; fax: +39 0115082860. E-mail address: fabrisans@katamail.com (F. Sansone). transfusion. After 2 months the patient died because of thoracic haemorrhage. The particularity of our report is the large dimension of the cardiac mass and the severe infiltration of the surrounding structures such as tricuspid annulus, right coronary artery and free wall of the right atrium. Previous reports [2–4] showed cardiac sarcoma originating from the tricuspid annulus or with the infiltration of the right coronary artery but this is the first report of a mass arising from the free wall of the right atrium infiltrating surrounding structures. In this case surgical resection was impossible for the large infiltration of the heart. Our report confirms that cardiac sarcoma is a lethal tumor and surgical excision, when possible, may be challenging without many chances of success. In conclusion, the “wait and see” approach in a 28-year-old patient is somewhat hard to accept but understandable because of the presence of a metastasis. However, the only way to improve prognosis of malignant cardiac tumors is to increase the grade of suspicion in order to increase the rate of an earlier diagnosis allowing for complete resection. Echocardiography and cardiac magnetic resonance are mandatory for complete assessment of the lesion and for the decision making process. This paper supports the concept that when symptoms such as dyspnea, palpitations and other cardiac related are concomitant to signs and symptoms concerning possible malig- nancy such as weight loss, the hypothesis of cardiac tumors should be considered and loose time during the diagnostic process may cause severe sequelae in the possibility of surgical resection of the lesion. Acknowledgement The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [5]. References [1] Maraj S, Pressman GS, Figueredo VM. Primary cardiac tumors. Int J Cardiol 2009;133(2): 152–6. [2] Kalangos A, Sierra J, Hohn L, et al. Cardiac sarcoma originating from the tricuspid valve. J Card Surg 2001;16(2):173–5. [3] Paruchuru PK, Brann SH, Patel RL. Primary left atrial fibrosarcoma. Cardiovasc Pathol 2001;10(6):317–9. [4] McElhinney DB, Carpentieri DF, Bridges ND, Clark BJ, Gaynor JW, Spray TL. Sarcoma of the mitral valve causing coronary arterial occlusion in children. Cardiol Young 2001;11(5):539–42. [5] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50. 0167-5273/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2010.09.025 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard