CORRESPONDENCE
on oral steroids. Magnetic resonance
Anesthetic
Management of a Case
of Posterior Fossa Tumor
With An Intracardiac
Mass
To JNA Readers:
Patients with an intracardiac
mass present unique challenges to an-
esthesiologists. The risks are perioper-
ative arrhythmia, thromboembolic
complications, cardiac dysfunction, and
increased postoperative morbidity.1
The presence of an intracranial mass in
such patients compounds the problem
because of limitation of perioperative
anticoagulation. An anecdotal case of a
left ventricular mass for extracranial
surgery has been reported.2 This report
highlights the case of a patient with a
posterior fossa lesion with a left ven-
tricular mass who was operated upon
in the prone position, which has not
been reported before.
A 58-year-old lady, weighing
65 kg, presented at our emergency de-
partment with a history of increasing
drowsiness since 3 days. She was a
known case of intracranial lymphoma
FIGURE 1. A, Transthoracic view showing the mass attached to the left ventricle. B, Transesophageal view showing the left
ventricular mass.
The authors have no funding or conflicts of
interest to disclose.
J Neurosurg Anesthesiol  Volume 00, Number 00, ’’ 2015
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
was visualized (Fig. 1B). With all mon-
imaging of the brain revealed a posterior
fossa space–occupying lesion with mass
effect. She was posted for craniotomy
and tumor decompression. Preanesthetic
evaluation revealed no significant medi-
cal history. Twelve-lead electrocardio-
gram showed T-wave inversion in
V2-V6. A 2D transthoracic echo revealed
a large pedunculated mass (2.9 1 cm)
in the left ventricle (Fig. 1A). The car-
diac surgeon’s opinion was obtained,
who advised anticoagulation and ex-
cision of the mass, but the patient was
advised neurosurgery first in view of her
deteriorating neurological condition.
The risks involved in such a patient were
discussed with the patient’s relatives and
informed high-risk consent was taken.
Apart from routine ASA monitors,
a transesophageal echocardiography
(TEE) was planned. In the operating
room, an 18-G intravenous cannula and
left radial artery were cannulated under
local anesthesia. Anesthesia was induced
with midazolam 2 mg, fentanyl 150 mcg,
lidocaine 60 mg, and propofol 50 mg.
Rocuronium (50 mg) was administered
to facilitate endotracheal intubation.
Anesthesia was maintained with oxygen
in air and sevoflurane (0.8 to 1.0 MAC).
A TEE probe was inserted and the
cardiac status was assessed. The mass
itors in situ, the patient was turned
prone. TEE assessment was performed
again in the prone position, keeping a
close watch on the left ventricular mass.
Surgery lasted for 160 minutes.
Throughout the surgery, TEE was
monitored. No significant cardiac dys-
function or embolic shower of cardiac
mass was noticed. A decision to ven-
tilate the patient electively was made
because of her poor neurological status.
The patient’s trachea was extubated
next day as she had good neurological
recovery. Low–molecular-weight hep-
arin, enoxaparin 0.6 mg, was started
subcutaneously twice a day after con-
sultation with the neurosurgery team.
She was discharged on the fifth post-
operative day in satisfactory clinical
condition on oral anticoagulation.
Intracardiac mass can be either a
tumor or an organized blood clot.3,4
Most common tumors are myxomas,
which are generally located in the left
atrium. In our patient, however, the mass
was present in the left ventricle, which
accounts for only 2.5% of cases.4 TEE
monitoring is an established modality for
monitoring intraoperative cardiac func-
tions in various surgical positions and for
detection of venous air embolism. In the
present case, however, continuous TEE
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Correspondence J Neurosurg Anesthesiol  Volume 00, Number 00, ’’ 2015

monitoring was of great help in keeping a
close watch on the left ventricular mass
lesion. To conclude, we recommend in-
traoperative TEE monitoring in patients
with an intracardiac mass.
Virendra Jain, MD, DM
Prabhakar S. Prakash, MD
Hari H. Dash, MD, MNMS
Department of Anaesthesiology and Pain
Medicine, Fortis Memorial Research
Institute, Gurgaon , Haryana, India
REFERENCES
1. Raut MS, Maheshwari A, Dubey S, et al.
Left ventricular mass: myxoma or throm-
bus? Ann Card Anaesth. 2015;18:95–97.
2. Bergman R, Shakil O, Mahmood B, et al.
Major surgery, hemodynamic instability,
and a left atrial appendage clot: what to
do? J Cardiothorac Vasc Anesth. 2013;27:
625–626.
3. Meller J, Teichholz LE, Pichard AD, et al.
Left ventricular myxoma: echocardiographic
diagnosis and review of the literature. Am J
Med. 1977;63:816–823.
4. Korkmaz AA, Tamtekin B, Onan B, et al.
Combination of right atrial and left ven-
tricular myxoma. Ann Thorac Surg. 2010;89:
e33–e35.

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Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.