Obstruction of the right ventricular outflow tract due to metastasis

The purpose of this report is to describe a case in which the sole clinical manifestations were those of right ventricular outflow tract obstruction. At operation this was found to be due to a myocardial metastasis in the infundibulum of the right ventricle. In retrospect there were radiological changes which might have suggested that the lesion was not congenital as had been presumed pre-operatively. The patient was a 52-year-old lady who had had intermittent swelling of the ankles for several years. In 1957 an ejection systolic murmur had been recorded at the left sternal edge and in March, 1969 she had developed severe swelling of the ankles and shortness of breath and was hospitalised and treated with digoxin and diuretics. From that time she remained short of breath on exertion and in June, 1969 had three episodes of paroxysmal nocturnal dyspnoea. She also complained of dysphagia and had lost 19 lb. in weight. There was no relevant past medical history or family history. Physical examination revealed a small, thin lady with a marked thoracic kyphoscoliosis. The pulse was regular at 80/minute and of low amplitude and the blood pressure was 120/80 mm Hg. There were 5 to 6 cm a and v waves in the jugular venous pulse. Examination of the heart was complicated by the severe chest deformity, but there was considered to be right ventricular enlargement, a loud pan systolic murmur at the left sternal edge, an ejection systolic murmur in the pulmonary area, and a third heart sound.