Thrombolysis and embolectomy in treatment of acute stroke as a bridge to open-heart resection of giant cardiac myxoma:A case report

BACKGROUND Cardiac embolism is a common cause of ischemic stroke in young adults.Neurological complications associated with atrial myxoma most frequently include cerebral infarct due to embolus.Early complete resection of giant cardiac myxoma is the key to its treatment and prevention of stroke recurrence.CASE SUMMARY A 42-year-old,previously healthy woman was admitted to the hospital with sudden-onset inability to speak and right-sided hemiplegia.While sweeping the floor 2 h prior to hospital admission,the patient developed sudden inability to express herself or understand what others were saying,accompanied by dyskinesia of the right limb,inability to walk or hold objects,and involuntary choreiform movements of the left upper limb.The patient was diagnosed with cerebral embolism and cardiac myxoma,complicated by left middle cerebral artery occlusion.The acute stroke was treated with intravenous thrombolytic therapy and arterial embolectomy as a bridging therapy to open resection of left atrial cardiac myxoma.The patient condition improved remarkably following initial thrombolysis and embolectomy and subsequently underwent emergency open resection of the atrial cardiac myxoma.She had no recurrence during 1-year follow-up.CONCLUSION Strong consideration should be given to urgent intravenous thrombolysis(rt-PA,alteplase)in young adult stroke patients at the time of hospital admission.The present case demonstrated a highly successful outcome that combined thrombolysis and arterial embolus retrieval as a bridge to early complete resection of a giant cardiac myxoma for both stroke treatment and recurrence prevention.

Familial cardiac myxoma with multifocal recurrences:a case report and review of the literature

We report a case of myxoma with multiple recurrences in both the atrium and ventricle in a 26-year-old woman five years after the surgical removal of left atrial myxoma, Her 52-year-old mother had a similar medical history. To our knowledge, this was the first familial case who suffered multifocal cardiac myxoma recurrences without any sign of the myxoma complex. Based on our understanding of the mechanism of recurrence, the approaches to prevent the recurrence, and markers to predict recurrence, we propose that multifocal recurrences, as reported herein, may result from a combination of familial predisposition and multifocal onset. The hi-atrial surgical approach and transesophageal echocardiography are preferred for patients with recurrent cardiac myxomas, especially for those with multiple recurrences and familial myxoma. Immunological and genetic screenings may help to identify family members at risk for developing this disease.

Cardiac myxoma shedding leads to lower extremity arterial embolism:A case report

BACKGROUND Left cardiac myxoma(CM)is the most common benign tumor of primary cardiac tumors,but because of its special position caused by pathological physiology change,caused by the complications of the heavier,the surface is often accompanied by blood clots,once fall out,it causes peripheral vascular embolization,such as acute lower limb artery embo-lization,harmfulness is large,high morbidity,and easy to occur repeatedly.CASE SUMMARY A 67-year-old male patient suddenly appeared numbness and weakness of the left lower limb and could not walk without obvious incentive.The patient was finally diagnosed as left CM complicated with acute lower limb arterial embolism after completing cardiac ultrasound,computer tomography angiography,and histopathological analysis,such as hematoxylin-eosin stain staining,immunohistochemistry and special staining including alcian blue staining and periodic acid schiff staining.Arterial thrombosis was removed successfully by femoral artery thrombectomy,postoperative numbness and weakness of the patient’s left lower limb disappeared,skin temperature became warm,and dorsal foot artery pulsation was accessible.The patient was readmitted to the hospital 8 mo after discharge for left atrial mass resection,and was diagnosed as CM by postoperative histopathological examination.CONCLUSION Although CM is rare,it may be considered as the source of embolism in patients with acute limb ischemia.Repeated loss of thrombus on the tumor and its surface may lead to repeated embolism of peripheral vessels.Cardiac ultrasound is helpful for early diagnosis.Here,we use this case report to highlight left CM as an important cause of acute limb ischemia and to report our experience in the diagnosis and treatment of lower limb arterial embolism caused by CM detachment.

Clinical Signifi cance of Angiographically Detectable Neovascularity in Patients with Cardiac Myxoma

Background:Myxomas are the most common primary cardiac tumors.Angiographically detectable neovascularity(ADN)of myxoma is increasingly being reported as a result of the use of coronary angiography(CAG)to detect coronary artery disease.However,the clinical signifi cance of these fi ndings is not fully understood.Methods:We enrolled 59 patients with cardiac myxoma who also underwent CAG between January 2013 and October 2018.Patients were followed up for a mean of 28.9 months(range 1-69 months).The clinical features,echocardiography measurements,pathological examination fi ndings,CAG results,and outcomes during follow-up were compared between patients with ADN and patients without ADN.Results:ADN was found in 25 patients(42.4%).The arteries feeding the ADN included the right coronary artery(n=15),the left circumfl ex coronary artery(n=7),and both arteries(n=3).The patients with ADN had a higher proportion of eosinophils(3.2%vs.2.2%,P=0.03)and higher low-density lipoprotein cholesterol level(2.7 mmol/L vs.2.2 mmol/L,P=0.02).Myxoma pedicles were more likely to be located in the interatrial septum in patients with ADN(96%vs.73.5%,P=0.02).No signifi cant correlation was observed between the groups in clinical manifestations,atrial arrhythmia,myxoma size,cardiac chamber size,left ventricular ejection fraction,and the prevalence of complication with coronary artery disease[16%in the ADN group(n=4)vs.20.6%in the non-ADN group(n=7),P=0.66].However,patients with ADN tended to have a lower incidence of major adverse cardiac and cerebrovascular events on long-term follow-up(0%vs.14.7%,P=0.07).Conclusion:CAG-detected ADN in patients with cardiac myxoma is associated with a borderline lower rate of major adverse cardiac and cerebrovascular events.

Cardiac Myxoma: 10 Years Study of Presentations, Resection and Outcome

Background: Cardiac myxoma is a very rare heart tumor which presents as life threatening mass in cardiac chamber. The tumor may present with vague symptoms which can lead to delay in diagnosis. Methods: 22 patients underwent complete excision of intracardiac myxoma between January 2011 and December 2020. Majority of the patients were females (60%) with mean age of 48.9 years who presented with symptoms of dyspnea on exertion. 3 patients had significant complications due to myxoma. 2 presenting with tumor embolism and limb ischemia while 1 patient presented with pulmonary edema. All patients were diagnosed by echocardiography which helped in evaluation of size and extent of tumor. Majority of patients underwent trans-septal biatrial approach for tumor excision. Results: 95% of patients survived the operation. The mean tumor size excised was 5.0 ± 1.6 cm in the largest diameter. 11 patients had sessile tumor while 1 patient had dumb bell tumor occupying both atria. 15 patients were surviving the operation while 2 deaths happened after 6 years of surgery. Conclusion: Cardiac myxomas are rare tumors which can cause severe systemic and cardiac symptoms in patients. Early diagnosis and immediate surgical management give excellent early and long-term results.

Six Years Clinical Experience and Surgical Considerations in Management of Cardiac Myxoma in Iraqi Center for Heart Disease—Single Center Experience

Background: Cardiac myxomas are the most frequently encountered benign cardiac tumors that if left untreated are inexorably progressive and potentially fatal. Surgery is the only way of treatment, and if not treated with the right surgical technique recurrence occurs. Objectives: In this single center study we documented the patterns of presentation, localization, surgical approaches and outcome of cardiac myxomas. Methods: This is a retrospective study of 20 patients who underwent surgical removal of atrial myxoma from January 2010 to December 2015. All patients underwent general investigations, and echocardiography was performed on all patients and surgery was done using extracorporeal circulation and mild hypothermia. Results: The ages of the patients ranged from 14 years to 71 years, with a mean of 51.45 years. Most myxomas (75%) originated from left atrium, 20% from right atrium and biatrial in 5% of cases. The male-to-female ratio was 1:2.3 (14 females and 6 males). Myxomas were more common in blood group A+ and B+. Chief complaints were dyspnea (70%) and palpitation (50%). The majority of masses were attached to the interatrial septum (65%) and four of cases (20%) arose from the lateral wall. Right atrial trans-septal incision was used in 55% of cases. No recurrence was recorded in our study. Six patients had postoperative complications, mainly in the form of arrhythmia (3 cases), bleeding (0ne case) and renal failure (one case) which resulted in the death of the patient. Conclusions: Cardiac myxoma excision account for a very small percentage of cardiac procedures. Immediate surgical treatment is indicated because of high risk of embolization and sudden death. Cardiac myxomas can be excised with a low rate of mortality and morbidity. Follow-up examination, including echocardiography, should be performed regularly.

Primary Cardiac Tumors Operated on in Côte d’Ivoire: They Are Almost All Myxomas

Objective: Through this surgical series, we present the epidemiological and anatomical-clinical aspects and the surgical results concerning patients operated on for a primary cardiac tumor at the Abidjan Heart Institute. Materials and Method: This is a retrospective descriptive study covering the period of January 1982 to December 2022, based on the medical records of patients operated on for a primary cardiac tumor at the Abidjan Heart Institute. Results: Twenty-seven (27) patients underwent surgery for a primary cardiac tumor, including 14 women and 13 men with a mean age of 41.5 years (range 19 - 76 years). The main circumstances of discovery were exertional dyspnea, palpitation and syncope or pseudo-syncope. The main site was the septal wall of the left atrium. The diagnosis of myxoma was confirmed by pathological examination of the surgical specimen in 96.3% (n = 24) of the patients and it was a malignant large cell immunoblastic lymphoma of the myocardium in 3.7% (n = 1) of the patients. The mean largest diameter was 46.1 mm. The postoperative course was marked by an ischaemic stroke (n = 1);recurrence of a left atrial myxoma 5 years after the first tumor removal (n = 1). Two cases of death were noted, one due to the evolution of immunoblastic large cell lymphoma and the other due to an extracorporeal circulation accident. Conclusion: Almost all primary cardiac tumors operated on in Abidjan are myxomas. The circumstances of the discovery of these cardiac tumors are multiple and varied but dominated by exertional dyspnea, palpitation and syncope. Whatever their histological type, primary cardiac tumors are serious affections, in view of the haemodynamic and rhythmic disorders they cause.

Risk factors for postoperative recurrence of cardiac myxoma and the clinical managements： a report of 5 cases in one center and review of literature

Background Recurrence or metastasis of myxomas is not rare risk factors for postoperative cardiac myxoma recurrence and to classification. and can lead to malignancy. We aimed to analyze the summarize its clinical characteristics, treatments and Methods The clinical data of 5 patients with recurrent cardiac myxoma were retrospectively analyzed and our clinical experience was summarized. Moreover, the relevant literatures were reviewed. Results All the five cases of primary myxomas were derived from atypical positions. One patient had early distant metastasis, one had family history, and two suffered malignant recurrence. The recurrence interval was （2.30＋2.16） years and the recurrent tumors were all found in different chambers from those of the corresponding primary tumors. Re-operation was performed after recurrence. One patient died of heart failure after malignant recurrence, and the other 4 cases had satisfactory therapeutic outcomes after re-operations. Our experience advocated a clinical classification of ＂typical＂ and ＂atypical＂ cardiac myxoma, the typical myxomas referred to the tumors locating at the left atria, with single pedicle, rooted at or around the fossa ovalis, involving no genetic causes, and the atypical myxomas included the familial tumors, tumors stemming from multiple chambers, rooted in abnormal positions of the left atrium, with evident genetic mutation, or with malignant tendency.

Acute Myocardial Infarction: Mode of Revelation of a Left Atrium Myxoma

True, cardiac myxoma is a benign tumor. On the other hand, it is serious by its complications, in particular embolic. The diagnosis of acute coronary syndrome in connection with a myxoma of the left atrium is retained before the association of an emboligenic intracardiac myxoma and an acute coronary syndrome in the absence of atherosclerotic lesions and the absence of intracardiac thrombus. We report a case of left atrium myxoma complicated by acute coronary syndrome in a 50-year-old patient operated on in our department and we will review the literature.

心脏黏液瘤相关缺血性脑卒中临床特点和危险因素的单中心队列研究

目的 探讨心脏黏液瘤相关缺血性脑卒中的临床特点和危险因素,为心脏黏液瘤相关缺血性脑卒中的早期识别和诊断提供依据。方法 回顾性收集2010年1月至2020年12月就诊于首都医科大学附属北京安贞医院的心脏黏液瘤患者408例。分析心脏黏液瘤患者和心脏黏液瘤相关缺血性脑卒中患者的临床表现,并分析心脏黏液瘤相关缺血性脑卒中的危险因素。结果 全部408例心脏黏液瘤患者中,396例纳入分析,其中包括48例心脏黏液瘤相关缺血性脑卒中患者和348例心脏黏液瘤非脑卒中患者。心脏黏液瘤的临床症状不典型,以心脏梗阻、栓塞和全身系统症状为主。在心脏黏液瘤相关缺血性脑卒中急性期,患者神经功能缺损为轻中度,美国国立卫生研究院卒中量表评分为3(1,10)分,大部分患者(56.3%,27/48)以神经系统症状为首发和唯一表现。多因素Logistic回归分析结果显示,肿瘤宽度<30 mm、肿瘤高活动度、肿瘤表面血栓形成和B型脑钠肽(BNP)水平较低均为心脏黏液瘤相关缺血性脑卒中的独立危险因素(均P<0.05)。结论 心脏黏液瘤临床表现多样。心脏黏液瘤相关缺血性脑卒中患者急性期表现为有轻中度神经功能缺损。较窄的肿瘤宽度、肿瘤高活动度、肿瘤表面血栓形成和较低的BNP水平是心脏黏液瘤相关缺血性脑卒中发生的独立危险因素。

心脏黏液瘤合并缺血性卒中的手术方式和术后管理

目的探讨心脏黏液瘤合并缺血性卒中(cardiac myxoma combined with ischemic stroke,CM-IS)的手术方式、术后并发症及术后抗栓治疗,为心脏黏液瘤导致的心源性卒中的手术方式和术后管理提供依据。方法心脏黏液瘤分别采用传统胸骨正中开胸手术和经胸骨右侧第四肋间微创手术两种手术方式。回顾性收集了2010年1月1日至2020年12月31日于北京安贞医院住院治疗的全部心脏黏液瘤患者,并将患者分为心脏黏液瘤合并缺血性卒中组和非卒中组,对部分患者进行短期随访。分析心脏黏液瘤合并缺血性卒中的手术方式、术后并发症,术后抗栓治疗及短期预后。结果共有387例患者纳入分析,其中包括45例缺血性卒中患者和342例非卒中患者。缺血性卒中患者在胸骨正中切开术中,体外循环阻断时间(62.7 min±23.7 min vs.63.2 min±27.4 min,P=0.921)、住院天数(10.2±3.0 vs.10.0±3.5,P=0.596)和术后并发症(15.0%vs.9.5%,P=0.283),与非卒中患者均无显著差别,缺血性卒中患者同时行冠脉搭桥手术的比例更高(17.5%vs.5.6%,P=0.005),同时行心脏瓣膜手术的比例较低(2.5%vs.16.8%,P=0.018)。缺血性卒中患者在微创手术中,体外循环阻断时间(66.6 min±27.5 min vs.69.7 min±29.9 min,P=0.460)、住院天数(9.1±1.8 vs.11.2±4.3,P=0.268)和术后并发症(20.0%vs.13.2%,P=0.678),与非卒中患者亦无显著差别。缺血性卒中患者术后使用抗栓治疗的比例(37.8%vs.39.8%,P=0.471),与非卒中患者无显著差别;随访期间无脑卒中复发,死亡(4.3%vs.2.0%,P=0.481)和黏液瘤复发(2.2%vs.1.8%,P=0.825)的比例,两组亦无显著差别。缺血性卒中患者3年生存率为95.7%(95%CI:94.9~96.5)。结论心脏黏液瘤合并缺血性卒中患者在黏液瘤切除手术方法中,无论采取胸骨正中切除术,还是微创手术,都是安全、有效的,术后并发症少。卒中患者在黏液瘤切除术后无需常规给予抗栓治疗,预后良好,生存率高。

基于临床和超声特点的二元Logistic 回归模型预测心脏黏液瘤血管栓塞事件

目的基于临床和超声特点探究心脏黏液瘤(cardiac myxoma,CM)患者并发血管栓塞(vascular embolism,VE)的危险因素,并构建预测CM患者VE事件的二元Logistic回归模型。方法回顾性筛选2016年6月-2023年7月于山东大学齐鲁医院德州医院经病理证实为CM的患者120例,根据术前有无发生VE分为VE组和对照组,收集并对2组临床和超声心动图特点行单因素和多因素分析,建立Logistic回归模型,以采用受试者工作特征(ROC)曲线和Hosmer-Lemeshow检验评估模型的预测效能和拟合能力。结果单因素分析显示年龄、吸烟史、肿瘤形态和结构是CM患者VE发生的影响因素;多因素分析显示吸烟史、肿瘤形态不规则、肿瘤结构疏松是CM患者并发VE的独立危险因素。结论基于临床和超声特点建立的二元Logistic风险预测模型且具备较好的预测效能和拟合能力,可为心脏黏液瘤患者血管栓塞的预防提供一定的参考依据。

Cardiac metastasis from colorectal cancer:A case report

The heart is an unusual site of metastasis from any malignancy.We report a case of cardiac metastasis from colorectal cancer.A 70-year-old woman was referred with a presumptive diagnosis of sigmoid colon cancer with cardiac myxoma.Two-dimensional echocardiography showed a 4 cm × 4.5 cm mobile mass on the lateral right atrial wall,and computed tomography revealed a low attenuated lobulating mass in the right atrium.The patient underwent anterior resection for sigmoid colon cancer(T4N2).Thereafter,she experienced progressive shortness of breath.Therefore,a cardiac operation was performed 2 wk after the colorectal operation.Histological examination revealed adenocarcinoma,which was identical to the primary lesion.Although two-dimensional echocardiography has become the diagnostic test of choice for detecting cardiac tumors,in patients with colorectal cancer showing a cardiac mass,further diagnostic evaluation such as a magnetic resonance imaging might be necessary.

THE CLINICOPATHOLOGICAL AND PROGNOSTIC STUDY ON 42 CASES WITH CARDIAC TUMOR

Objective: To analyze the relation between the pathological changes and the clinical manifestations and the prognosis of cardiac tumors through the pathological study on 42 cases with cardiac tumor, in order to improve the knowledge of the tumors, to make early diagnosis and to raise the curative ratio.Materials and Methods: 42 confirmed cardiac tumors of our department were selected, among whick 41was surgical specimen and 1 was autopsy. The study was Pcrformed by using the common and special histochemical staining.Results: 41 is Primary and 1 is secondary which is a metastazed hepatocelular carcinoma. In the Primary ones,39 (95.1%) is benign, including myxoma, fibroma,rhabdomyoma and Pericardial cyst, while 2 (4. 9%) is malignant, including neuroleminafibrosarcoma and malignant mesothelioma. In the myxomas, female patients occupy 75%, 91.7% exists in the left atrium and every one has got a peduncle adbesive to the fossa ovalis or adjacency of the atrial septum.Conclusions: The results of the pathological and prognostic study sbowes cardiac tuinors are quite different from the tumors in other sites, i.e., cven benign ones could cause fatal hemodynamic disturbance. Hence early diagnosis and early operation are necessary and if in such instance, the Prognosis of inost of the benign oncs would be good. But the prognosis of the malignant tumors is worst. The myxomas are different from the organized thrombi in heart cavity. And also the criteria of diagnosis and differential diagnosis are discussed.

Right Ventricular Myxoma Causing Right Ventricular Outflow Tract Obstruction: A Case Report

A 63-year-old patient presented with dyspnea and chest distress. A computerized tomography and echocardiogram showed a cardiac mass in the right ventricle, which caused obstruction of the right ventricular outflow tract. Coronary angiography revealed a dense meshwork of the abnomorly capillary vessels originating from right coronary artery. The mass was completely excised under cardiopulmonary bypass. The mass attached right ventricle lateral wall and posterior triscupid leaflet. Histology was typical myomatous tissue.

完全胸腔镜微创手术治疗心脏粘液瘤的效果及并发症研究

目的 探讨完全胸腔镜微创手术治疗心脏粘液瘤的效果及并发症。方法 回顾性分析心脏粘液瘤患者81例,根据手术方式的不同将入组患者分为观察组(n=46)和对照组(n=35)。对照组患者采用传统开胸手术治疗,观察组患者采用完全胸腔镜微创手术治疗。记录2组患者手术相关指标(术中出血量、气管插管时间、手术时间、手术切口及体外循环时间)和术后恢复指标[住院时间、住重症监护室(ICU)时间及疼痛程度]。于手术前后,比较2组患者心肌谱酶指标[肌钙蛋白I(cTnI)、肌酸激酶(CK)及乳酸脱氢酶(LDH)]及心功能指标[左心室射血分数(LVEF)、左心室舒张末期内径(LVEDD)及左心室收缩末期内径(LVESD)];并记录患者并发症的发生情况。结果 观察组患者术中出血量、气管插管时间、手术切口均显著少(短)于对照组,体外循环时间显著长于对照组,差异具有统计学意义(P<0.05);2组患者手术时间比较无显著差异(P>0.05);观察组患者住院时间、住ICU时间及VAS评分均显著短(低)于对照组,差异具有统计学意义(P<0.05)。术后2组患者LVEDD、LVESD水平均降低,LVEF水平升高,但2组比较无统计学差异(P>0.05);术后2组患者CK及LDH水平升高,cTnI水平降低,但2组比较差异无统计学意义(P>0.05)。观察组患者并发症发生率显著低于对照组(8.70%vs 25.71%)(P<0.05)。结论 完全胸腔镜微创手术治疗心脏粘液瘤具有较高的安全性,术中出血量较少,并发症较少,有助于术后早期恢复。

Acute Respiratory Distress after Knee Arthroplasty Due to Undiagnosed Atrial Myxoma

Acute postoperative respiratory distress may be caused by pneumonia, pulmonary embolism, heart failure, pneumothorax or atelectasis. We present s case report of a 78-year-old female patient who developed acute respiratory distress one day following knee arthroscopy. Because of the suspicion of pulmonary embolism, a computed tomographic angiography was made, showing the presence of an unexpected large left atrial mass, suggestive for a myxoma. She underwent successful resection of a 10 × 5 cm myxoma one week later. The report discusses the clinical manifestations of an atrial myxoma and its potentially fast growth. Bedside echocardiography should be considered the preferred diagnostic modality in case of acute postoperative respiratory distress.

Atrial Myxoma with a Dual Coronary Artery Supply

Primary cardiac tumours are rare, with myxoma being the most common benign heart tumour. The prevalence of coronary disease or neovascular in patients with atrial myxomas is high, yet angiography is not routinely performed. Echocardiography is preferred for evaluation of myxoma, where coronary angiography clarifies the vascular supply of the tumour and may alter the surgical planning. We here report an interesting and rare case of a left atrial myxoma hyper vascularised by two anomalous arteries, from right coronary artery and circumflex artery demonstrated by preoperative coronary angiography. The mass was successfully excised and the diagnosis of cardiac myxoma was confirmed via histopathology. A review of the value of coronary angiography in detecting myxoma neovascularization is provided. Offering additional valuable information, coronary angiography can alter the surgical approach and may therefore be considered prior to myxoma resection.

双房粘液瘤的临床诊疗分析

目的:通过分析双房粘液瘤(BM)的临床特点,总结围术期治疗经验及中短期预后效果。方法:回顾性分析2004年12至2021年5月,北京安贞医院心外科6例双房粘液瘤患者的临床资料,结合国内外相关文献与本组患者术前资料,手术治疗及围术期处理进行分析总结。结果:6例患者均行粘液瘤切除术,术后6例患者心功能均有不同程度改善,无围术期死亡病例,中短期预后良好。结论:双房粘液瘤患者早期明确诊断,尽早行手术治疗可降低并发症发生,降低围术期风险,提高预后效果。

Right Ventricular Myxoma—A Case Report

From an epidemiologic perspective, cardiac myxomas are best divided into the following 2 categories: those that arise in isolation and those that arise in the setting of a syndrome (so called Carney Complex). The former account for about 90% - 95% of cases, while the later account for a minority of cases and those arise from the right or left ventricle constitute as 3% each. Real-time two-dimensional echocardiography has proved to be extremely useful in defining intracavitary masses. With two-dimensional echocardiography accurate visualization of the right ventricular body and outflow tract can be accomplished consistently. The acoustic nature and anterior location of the right ventricular myxomas make them appear as bright, mobile masses. The mobile nature of the tumor can easily be appreciated and its point of attachment, or stalk can be visualized accurately. Background of this case illustrates the transthoracic 2D echocardiographic pattern of right ventricular myxoma and its attachment by a pedicle to the anterior papillary muscle, masquerading as ball-valve thrombus and cardiac “stone” in tilted parasternal long axis-3 chamber views in a 15-year-old girl. Mahaim criteria to distinguish myxoma from organizing thrombus had been highlighted.