Unusual echographic manifestations of right and left heart myxomas.

Although echocardiography has provided a useful noninvasive means for detecting cardiac myxomas, the ultrasound manifestations of these tumors may be variable. We describe our experiences with unusual echographic features encountered in left and right heart myxomas. Thus the left atrial tumor may be manifested predominantly by multiple, discrete, linear echoes behind the mitral valve, the anterior leaflet of which may exhibit an abrupt mid-systolic posterior movement. In right heat myxomatous tumor arising from the septal tricupsid leaflet and adjacent interventricular septum, the echographic characteristics include a cloud of echoes throughout the cardiac cycle in the right ventricular outflow tract which are present in the right ventricle body only during relaxation and are anterior to the tricuspid valve in early diastole. Therefore, discrete linear echoes may be the principal echographic presentation of left atrial myxoma, and special attention should be focused on all areas of the tricuspid valve and right ventricle by ultrasound in patients in whom diagnosis of myxoma is suspected.     

Two dimensional echocardiographic detection of intraatrial masses

With two dimensional echocardiography, a left atrial mass was detected in 19 patients. Of these, 10 patients with rheumatic mitral stenosis had a left atrial thrombus. The distinctive two dimensional echocardiographic features of left atrial thrombus included a mass of irregular nonmobile laminated echoes within an enlarged atrial cavity, usually with a broad base of attachment to the posterior left atrial wall. Seven patients had a left atrial myxoma. Usually, the myxoma appeared as a mottled ovoid, sharply demarcated mobile mass attached to the interatrial septum. One patient had a right atrial angiosarcoma that appeared as a nonmobile mass extending from the inferior vena caval-right atrial junction into the right atrial cavity. One patient had a left atrial leiomyosarcoma producing a highly mobile mass attached to the lateral wall of the left atrium. M mode echocardiography detected six of the seven myxomas, one thrombus and neither of the other tumors. Thus, two dimensional echocardiography appears to be the technique of choice in the detection, localization and differentiation of intraatrial masses.     

Two-dimensional echocardiography in the diagnosis of left atrial myxoma.

We performed M-mode echocardiograms on 11 patients who later had left atrial myxomas removed at operations. Seven of these 11 patients were also examined with two-dimensional echocardiography. M-mode echocardiography showed the characteristic pattern of a left atrial mass entering the mitral orifice during diastole in nine of the 11 patients. M-mode echocardiographic findings were equivocal in two patients because a short tumour stalk prevented significant motion of the tumour. Cross-sectional echocardiography clearly showed a left atrial mass attached by a stalk to the interatrial septum in all seven patients examined, including one patient in whom the tumour was immobile. Three-dimensional measurements of tumour size made from orthogonal cross-sectional echocardiographic planes were within 6 mm of similar measurements made on the excised tumours.     

Limitations of echocardiographic techniques in evaluation of left atrial masses

Four patients with large left atrial masses documented angiographically or pathologically, or both, were studied with M mode echocardiography (four patients) and two dimensional echocardiography (three patients) within 2 to 5 days of angiographic or pathologic diagnosis. The left atrium appeared clear of echoes in two patients subsequently documented to have a left atrial thrombus weighing 35 and 100 g, respectively, and located within the body of the left atrium. Definitely abnormal echoes were visualized in a third patient only in the inferior aspect of the left atrium immediately beneath the posterior root of the aorta. Subsequently, a 70 g left atrial myxoma filling almost the entire left atrium was found. In the fourth patient, who had a 125 g left atrial myxoma, the two dimensional four chamber apical view demonstrated tumor filling almost the entire left atrium. Long axis cross-sectional and M mode echocardiograms less clearly demonstrated the extent of the mass. Even large left atrial tumors located within the body of the left atrium may not be apparent or may be underestimated in size by currently available ultrasonic techniques. The relatively homogenous nature of certain masses may be, in part, responsible for the inability to visualize some of them adequately with echocardiography.     

Detection of atypical right atrial myxoma by echocardiography

Atrial myxomas are the most common primary cardiac tumors. They are commonly found in the atria and are attached to the interatrial septum. We report a case of a right atrial cardiac myxoma in a 47-year-old woman who presented with fatigue, right-sided chest pain, and a syncopal episode. Echocardiography demonstrated an atypical attachment of the myxoma to the free wall of the right atrium. The features of cardiac myxoma and the role of echocardiography in the diagnosis and treatment of cardiac myxomas are also discussed.     

The surgical treatment of cardiac myxomas: 10 years of experience]

Over a ten-year period (September 1980-July 1990) 3172 patients underwent open heart surgery in our hospital. Twenty five patients (0.78%) had a cardiac myxoma. There were 18 female and 7 male patients, mean age of 32.3 +/- 21 years (4-61). Left atrial myxomas were diagnosed in 18 patients, left ventricular myxoma in three, right atrial myxoma in two, and one in right ventricle; there was a biatrial myxoma in one case, another had biatrial and left ventricular myxoma. The clinical manifestations of right sided myxomas was congestive heart failure. Patients with left myxoma frequently presented embolic episodes. Myxoma diagnosis was made by means of chest films, EKG and two-dimensional echocardiography which proved effective in twenty four of our patients; cardiac catheterization was performed in ten of them. Symptoms before diagnosis lasted an average of 16.3 months and mean time from diagnosis to operation was 6.6 days. Different surgical approaches are analyzed and discussed. Concomitant surgical procedures were performed in five patients: mitral annuloplasty in one, mitral valve replacement in four (two biological and two mechanical prosthesis). In eight patients the resulting septal defect due to resection of pedicle was closed with pericardial or dacron patches. There were two operative deaths due to pulmonary emboli in one and multiple organ failure in other. Cardiac myxoma is the more frequent primary neoplasm of the heart; its "benign" nature is doubtful; cure by surgical excision can be considered in vast majority of patients and its morbidity is reasonably low.     

Atrial myxoma: case report and a review of the literature

Atrial myxomas are the most common benign primary tumor of the heart and occur in as many as 3 in 1000 patients. These tumors are a major cause of patient morbidity and mortality. Although the majority of atrial myxomas occur in the left atrium, 3 separate familial myxoma syndromes can result in multiple myxomas in atypical locations. Approximately 50% of patients with myxomas may experience symptoms due to central or peripheral embolism or intracardiac obstruction, but 10% of patients may be completely asymptomatic. Screening for myxomas should involve a thorough history and physical examination and a transthoracic and/or transesophageal echocardiogram. Transthoracic echocardiography is approximately 95% sensitive for the detection of cardiac myxomas, and transesophageal echocardiography approaches 100% sensitivity. Though the majority of atrial myxomas are sporadic, it is imperative that first-degree relatives of patients with documented myxomas undergo screening for occult myxomas. Surgical removal of the myxoma is the treatment of choice and usually curative; however, myxoma recurrence does occur and is most frequently associated with a familial syndrome.     

Primary cardiac tumors: experience with 30 consecutive patients since the introduction of two-dimensional echocardiography

Experience with 30 consecutive patients who had a total of 32 primary cardiac tumors and who underwent two-dimensional echocardiographic examinations between January 1977 and June 1983 was reviewed. Most of the tumors were atrial myxomas (20 left and 4 right), and 30 were identified on echocardiography. Twenty-five patients, including 21 of 22 with atrial myxoma, underwent surgical resection on the basis of the echocardiographic examination, without preoperative angiocardiography. When the morphologic characteristics of the left atrial myxomas were studied statistically in relation to clinical abnormalities, large tumor size was most closely related to the number and type of associated clinical and laboratory abnormalities. The single exception was embolization, which correlated with echocardiographic tumor consistency. Since the introduction of two-dimensional echocardiography, the yearly incidence of cardiac tumor diagnosis at this clinic has increased several fold and the incidence of unexpected intraoperative diagnosis has been very low (one case). Echocardiography is the method of choice for clinical diagnosis. It has replaced angiocardiography for routine preoperative assessment, permits early diagnosis of cardiac neoplasms and provides insight into the pathophysiology of primary cardiac tumors.     

Embolus to the right atrium simulating myxoma

A space-occupying mass of the right atrium was found by two-dimensional echocardiography and angiography in a 68-year-old woman whose clinical diagnosis indicated multiple pulmonary emboli. Since right heart myxomas frequently cause pulmonary thromboembolism, the patient was initially diagnosed by noninvasive and invasive techniques as having a right atrial myxoma. Surgery, however, revealed the pathologic findings of large thrombi of the right atrium, femoral and iliac veins, and pulmonary arteries. This case vividly demonstrates that deep venous thrombosis may embolize and lodge in the right atrial cavity simulating a right atrial myxoma.     

Surgical treatment of atrial myxomas: a report of 20 cases

Twenty atrial myxomas were resected in 20 patients with the use of cardiopulmonary bypass, from the beginning of July 1966 through the end of June 1985, at Severance Hospital, Seoul, Korea. Nineteen patients had left atrial myxomas; 1 had a right atrial myxoma. Left atrial myxomas arose from the intra-atrial septum in 17 patients and from the left atrial appendage in 2 patients. The right atrial myxoma arose from the fossa ovalis. The 13 female and 7 male patients ranged in age from 14 to 63 years. Symptoms most often reported on presentation were those associated with mitral valve obstruction; other symptoms were associated with systemic embolization. The 1st 4 patients were tested with angiocardiography alone, and 3 of these were misdiagnosed. The last 16 were tested by angiocardiography, M-mode echocardiography, and 2-dimensional echocardiography, alone or in various combinations, and there were no further misdiagnoses. In our experience, 2-dimensional echocardiography was the most accurate method of diagnosing cardiac tumors. In 19 patients, surgical approach was through a median sternotomy; in the 20th patient, approach was through a left thoracotomy, due to a preoperative misdiagnosis of mitral stenosis. No intraoperative embolizations or deaths occurred. On follow-up of 17 patients during periods ranging from 6 months to 6 years, we had no late deaths, and only 2 patients suffered late complications: 1 had sudden right hemiparesis caused by an embolus 4 months after surgery (this improved upon conservative treatment); and 1 had a recurrence of tumor 3 years after surgery (the new myxoma was successfully resected). We conclude that patients who have undergone complete excision of benign myxomas now have an excellent prognosis, with minimal risk of intraoperative embolization and late recurrence. We conclude also that 2-dimensional echocardiography is an extremely accurate tool both in early diagnosis of intracardiac myxomas and in late follow-up after resection.     

Live three-dimensional transthoracic echocardiographic assessment of left atrial tumors

This preliminary study demonstrates the superiority of live three-dimensional transthoracic echocardiography (3D TTE) over two-dimensional (2D) TTE in the assessment of left atrial (LA) tumors in four patients studied by us (three myxomas, one hemangioma, all subsequently pathologically proven). Because of the unique ability of live 3D TTE to systematically section and view the contents of an intracardiac mass, LA myxomas in the three patients studied could be more confidently diagnosed by noting isolated echolucent areas consistent with hemorrhage/necrosis in the tumor mass. On the other hand, a definite echolucent area was found by 2D TTE in only two of the three patients with myxoma. In the fourth patient with a hemangioma, live 3D TTE showed much more extensive and closely packed echolucencies with little solid tissue as compared to a myxoma consistent with a highly vascularized tumor. In contrast, 2D TTE demonstrated only two isolated echolucencies in the tumor suggesting an erroneous diagnosis of myxoma.     

Left atrial myxoma infected with Streptococcus viridans

A case is described of Streptococcus viridans endocarditis involving a left atrial myxoma. The diagnosis was made by echocardiography and the infected tumour was successfully treated by surgical removal. A review of the published literature about left atrial myxomas underlines the importance of performing echocardiography in all patients with suspected endocarditis.     

Limitations of echocardiography in the diagnosis of left atrial myxoma: a case report

The classical echocardiographic features of left atrial myxoma are quite distinctive but do not comprise the full spectrum of abnormalities encountered. This case demonstrates atypical echocardiographic features of left atrial myxoma that initially obscured the correct diagnosis. Our findings underscore the potential limitations of echocardiography in the diagnosis of left atrial myxoma.     

Bilateral atrial myxomas. Surgical correction after echocardiographic diagnosis

A case is reported of bilateral atrial myxomas diagnosed noninvasivelyby echocardiography and successfully removed. The excised tumormass consisted of a mobile right atrial myxoma prolapsing intothe right ventricle and a less mobile, not prolapsing myxomain the left atrium. The operation was performed entirely onthe basis of echocardiographic findings, which correlated wellwith the operative results. Further investigation by computertomography verified the diagnosis, but added no extra informationof importance for therapy. Diagnostic aspects of the combinedapplication of M-mode and cross-sectional echocardiography withDoppler echocardiography are emphasized. Postoperative follow-upechocardiography showed the complete removal of the myxomasand improvement of cardiac function.     

Bilateral atrial myxomas. Surgical correction after echocardiographic diagnosis

A case is reported of bilateral atrial myxomas diagnosed noninvasivelyby echocardiography and successfully removed. The excised tumormass consisted of a mobile right atrial myxoma prolapsing intothe right ventricle and a less mobile, not prolapsing myxomain the left atrium. The operation was performed entirely onthe basis of echocardiographic findings, which correlated wellwith the operative results. Further investigation by computertomography verified the diagnosis, but added no extra informationof importance for therapy. Diagnostic aspects of the combinedapplication of M-mode and cross-sectional echocardiography withDoppler echocardiography are emphasized. Postoperative follow-upechocardiography showed the complete removal of the myxomasand improvement of cardiac function.     

Two dimensional echocardiography in differentiating right atrial and tricuspid valve mass lesions.

Atrial myxoma has been diagnosed on the basis of a characteristic M mode echocardiographic pattern of a mass of echoes appearing, with a lag phase, beneath the anterior leaflet of the mitral or tricuspid valve in diastole. However, this pattern is not specific for an atrial tumor. Two patients are described with tricuspid leaflet endocarditic vegetations whose M mode echocardiograms were strikingly similar to the M mode tracing from a patient with a large right atrial myxoma. In a fourth patient, artifact, resulting from the failure of lateral resolution of the atrial wall, was also capable of producing a mass of echoes appearing, with a lag phase, beneath the anterior tricuspid valve leaflet in diastole. In each patient, two dimensional echocardiography confirmed the presence or absence of a right-sided mass lesion and defined more precisely the location of the echocardiographic density relative to the right atrium and tricuspid valve. Because two dimensional echocardiography is capable of detecting anatomic relations in two distance dimensions and of visualizing movement of intracardiac structures relative to one another in real time, it can play an important role in the identification and differential diagnosis of intracardiac mass lesions.     

Cardiac tumors: clinical and echocardiographic diagnosis of 65 cases

65 cases of cardiac tumors were diagnosed and studied by echocardiography. Among them 49 were primary tumors including 43 cases of myxoma, one case each of hamartoma, lipomatous infiltration, fibroma, hemangioma, rhabdomyosarcoma, pericardial mesothelioma, and 16 cases of secondary cardiac tumors. It was found that the nature of primary cardiac tumors could be speculated by two-dimensional echocardiography based on their pathological features. Most patients with large left atrial myxoma had obstructive symptoms of mitral valves, abnormal ECG and enlarged left atrium, whereas patients with small atrial myxoma, embolic phenomenon was liable to occur. Echocardiography of secondary cardiac tumors showed that the tumors usually invaded most frequently both the myocardium and pericardium as single or multiple nodular echoes in the myocardium under pericardium or within the pericardial cavity, with profuse pericardial effusion. Occasionally, the secondary tumor appeared as a large mobile intracavitary mass or an extracardiac one compressing the heart or large vessels. It was noticed that cardiac symptoms might be the clinical clue in certain patients with extracardiac primary malignancy.     

Asymptomatic Left Ventricular Myxoma in a 12-Year-Old Male

Cardiac myxoma is the most common cardiac tumor in patients of all ages; the majority are encountered as single left atrial tumors. Left ventricular myxomas are exceedingly rare, having been recorded in a small number of case reports involving children worldwide. We report a case of a left ventricular myxoma with left ventricular outflow tract obstruction in a previously healthy, asymptomatic adolescent black male. Transthoracic echocardiograms revealed a single, large (2.5 × 5-cm), lobulated, mobile mass within the left ventricular cavity that oscillated into the outflow tract, thereby causing moderate obstruction during systole. Advanced images delineated the location and tissue composition of the mass, characterizing it as a myxoma. Complete surgical excision of the mass was accomplished via aortotomy. Gross examination and histology confirmed the diagnosis of myxoma.     

64例心脏粘液瘤外科治疗分析

本文报道64例心脏粘液瘤的手术治疗。术中发现粘液瘤在左心房56例,右心房7例;左心室1例。左心房粘液瘤中有2例为恶性粘液瘤。64例肿瘤均在体外循环直视下切除。术前确诊依靠超声心动图和多普勒检查,手术后死亡3例,死亡率为4.7%。