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.     

Echocardiographic pattern of right atrial tumour motion.

Propagation of Wilm's tumour to the right atrium was diagnosed by echocardiography. The tumour prolapsed into the right ventricle during each atrial systole. The presence of the tumour and its motion were confirmed by cardiac catheterization, cineangiography, and surgical exploration. Successful resection of the tumour was accomplished. Echocardiography was helpful in detecting the presence of the right atrial tumour and accurately reflected the pattern of its atrioventricular motion.     

Echocardiographic pattern of right atrial tumour motion.

Propagation of Wilm's tumour to the right atrium was diagnosed by echocardiography. The tumour prolapsed into the right ventricle during each atrial systole. The presence of the tumour and its motion were confirmed by cardiac catheterization, cineangiography, and surgical exploration. Successful resection of the tumour was accomplished. Echocardiography was helpful in detecting the presence of the right atrial tumour and accurately reflected the pattern of its atrioventricular motion.     

Right atrial rhabdomyoma acting as the substrate for Wolff-Parkinson-White syndrome in a 3-month-old infant

We report a 3-month-old infant girl who presented with supraventricular tachycardia, who was detected to have a large right atrial rhabdomyoma and evidence of Wolff-Parkinson-White (WPW) syndrome with an accessory pathway corresponding to the position of the tumour. In view of the resistant cardiac arrhythmia and large size of the tumour, the infant underwent surgical excision of the tumour. The evidence of WPW syndrome disappeared from the surface electrocardiogram immediately upon removal of the tumour. A second resolving tumour in the interventricular septum was also detected during the investigation. Although there are no other stigmata of tuberous sclerosis at present, our infant requires close follow-up. Right atrial rhabdomyomas are rare and to our knowledge this is the first reported instance where we could document clearly that the tumour itself formed the substrate for the WPW syndrome.     

Abnormal diastolic movement of the interventricular septum caused by a prolapsing right atrial myxoma

A 40 year old woman with cough and exertional dyspnoea was found to have a large right atrial myxoma by M mode and cross sectional echocardiography. Prolapse of the tumour into the right ventricle occurred during diastole with sufficient force to cause mechanical distortion of the interventricular septum. Septal motion became normal after surgical resection of the myxoma.     

Abnormal diastolic movement of the interventricular septum caused by a prolapsing right atrial myxoma.

A 40 year old woman with cough and exertional dyspnoea was found to have a large right atrial myxoma by M mode and cross sectional echocardiography. Prolapse of the tumour into the right ventricle occurred during diastole with sufficient force to cause mechanical distortion of the interventricular septum. Septal motion became normal after surgical resection of the myxoma.     

Comparison of mono and bidimensional echocardiography in the diagnosis of atrial myxoma

The diagnosis of atrial myxoma, the most common cardiac tumour, has been greatly facilitated by the introduction of echocardiography. The principal echocardiographic features and the diagnostic pitfalls encountered in a personal series of 7 atrial myxomas (5 left and 2 right) studied by M mode and 2-dimensional echocardiography are reported. In M mode, left atrial myxoma is a relatively easy diagnosis when the tumour prolapses into the mitral orifice. On standard mitro-aortic scanning, it is recorded behind the anterior mitral leaflet as a mass of abnormal echos appearing shortly after mitral valve opening. The diagnosis is much more difficult or even impossible in nonprolapsing tumours. Right atrial myxomas, prolapsing into the tricuspid orifice, do not usually pose any diagnotic problems. 2-dimensional echocardiography shows its superiority in the early diagnosis of small, localised, relatively immobile and non-prolapsing tumours. The parasternal (long axis and transverse views), the apical (4 and 2 chamber views) and subxiphoid positions were the most useful incidences and the tumour was visualised as a more or less circumscribed mass of echos. In all cases, 2-dimensional echo provided information on the size, mobility, insertion and the length of the pedicle of the tumour. Atrial myxoma is being recognised more easily and more often nowadays by echocardiography, the diagnostic method of choice, and 2-dimensional studies should be preferred.     

Left auricular myxoma. Apropos of 9 cases. Study of echocardiographic and morphologic aspects. Familial inquiry]

A study was made of 9 cases of left atrial myxoma with emphasis on the echocardiographic, haemodynamic and anatomical aspects and on the main clinical features. An epidemiological enquiry was made regarding the possibility of recurrences or familial cases. It was negative, suggesting that such cases are rare. The echocardiographic signs of left atrial myxoma are inconstant. The mitral diastolic EF slope is variable, the delay in appearance of the tumour echo behind the mitral valve in diastole is not constant, and the atrial "a" wave may be preserved. The echocardiographic features are a function of the size and shape of the myxoma, as well as the length and site of implantation of its pedicle.     

Left atrial myxoma-influence of tumour size on electrocardiographic findings

ObjectiveThe data of 51 patients (33 females) who underwent excision of left atrial (LA) myxoma were retrospectively reviewed for correlation of tumour size and electrocardiographic (ECG) findings.Methods and resultsMean age was 39.1 ± 15 years (range 9–53 years). The LA enlargement (LAE) on ECG was defined by standard criteria. The LAE in ECG in these patients did not correlate with echocardiographic LA dimensions or with the degree of left ventricular (LV) inflow obstruction. But it was found that the presence of LAE in ECG predicted maximum tumour dimension of >5 cm and correlated with the degree of mitral regurgitation (MR). The LAE in ECG disappeared following surgery in 87.5% of patients.ConclusionThe LA enlargement on ECG in a patient with LA myxoma signifies larger tumour size or the presence of significant MR but is not necessarily associated with an increased LA size or LV inflow obstruction.     

Recurrence of an atrial myxoma.

A 22-year-old man had an operation 14 years ago for removal of a left atrial myxoma. He was admitted to our hospital because of acute femoral arterial embolism. Echocardiographic examination revealed a mobile pedunculated echodense atrial mass attached to the atrial septum. At operation, the left atrium was found to be occupied with a gelatinous pale mass attached by a stalk to the atrial septum. The tumour was extirpated along with a part of atrial septum, which was assumed to be involved in the tumour. The atrial septal defect created was closed with patch. Histopathological examination of excised material revealed typical features of a myxoma.     

Relationship between interatrial pressure gradient and motion of the interatrial septum

To evaluate interatrial septal motion throughout the cardiac cycle, echocardiograms of the septum were obtained by esophageal echocardiography simultaneously with left and right atrial pressures using Millar's micromanometers in nine subjects with sinus rhythm. There were four patients with atypical chest pain but with normal coronary arteries, two with old myocardial infarction, one with angina pectoris, one with aortic regurgitation and one with sick sinus syndrome. The relationship between interatrial pressure gradient (IAPG: left atrial pressure minus right atrial pressure) and the motion of the septum was examined. In all nine patients, the curves of IAPG showed two peaks near the second heart sound and during the atrial contraction period, and the motion of the septum throughout the cardiac cycle showed a similar pattern except during the late diastolic period. During atrial contraction the septum moved posteriorly (decrease in left atrial dimension) against the IAPG. Therefore, except during the atrial contraction period, the motion of the atrial septum is considered to be dependent on this pressure gradient. During the atrial contraction period, the direction of the septal movement might be dependent on the force of active contraction of the left atrial muscles.     

Abscess of the mitral annulus mimicking left atrial tumour - case report

A case of a 70-year-old female with hypertension, atrial fibrillation and angina pectoris, admitted to the hospital due to echocardiographically detected left atrial tumour, is presented. Differential diagnosis included thrombus, myxoma, infectious or neoplastic tumour. The patients underwent surgery. Histopathological examination revealed the presence of an abscess in the left atrium. This report underlines the difficulties in the diagnosis of cardiac tumours.     

Abnormal right ventricular size and ventricular septal motion after atrial septal defect closure: etiology and functional significance.

Postoperative echocardiogram often demonstrate persistent right ventricular dilatation and paradoxic ventricular septal motion after repair of an atrial septal defect. To determine the prevalence, causes and significance of these echocardiographic abnormalities, 31 patients were studied with catheterization and echocardiography before and after repair of an atrial septal defect. Before operation, every patient manifested right ventricular dilatation, and all but one had abnormal septal motion. After operation, right ventricular dilatation was noted in 24 (77%) and abnormal septal motion in 21 (68%) patients despite the absence of residual left to right shunting in 30 (97%). These echocardiographic abnormalities could be correlated with age at operation and length of postoperative follow-up study but did not correlate with the degree of preoperative right ventricular enlargement or with shunt size or right ventricular pressure before or after operation. There was no associated functional deficit as demonstrated by the normal maximal oxygen consumption in all 13 patients who underwent treadmill exercise testing 5 to 38 months after operation; these patients included 9 with persistent right ventricular enlargement and abnormal septal motion.     

Echocardiographic evaluation of the significance of shunt in secondary communications and in partial abnormal pulmonary venous returns]

Although echocardiography has been useful in diagnosing significant left-to-right shunts at the atrial level, few studies using this technique to quantitate shunt size have been performed. Echocardiograms and hemodynamic data from 28 patients, ages 15 to 58 (mean : 30 years) were reviewed. Twenty patients had isolated atrial septal defects (ASD), 6 patients has associated partial pulmonary venous returns (PPVR) and 2 patients had isolated PPVR. Echocardiograms in the supine position were performed within 24 hours preceding cardiac catheterization. The presence or absence of paradoxical septal motion was noted and right ventricular diameter index (RVDE : right ventricular diameter/body surface area) was calculated. Hemodynamic parameters studied included pulmonary to systemic flow ratio (Qp/Qs) determined by oxymetry, right ventricular pressure (RVP) and pulmonary resistance (PR). One patient with a Qp/Qs of 1.3 had normal septal motion. Type A paradoxical septal motion was noted in 22 cases, type B in 5 cases. For these 27 patients, the average RVDI was 2.42 (range 1.45 to 3.7), Qp/Qs ranged from 1.5 to 5 (mean : 2.45), RVP from 23 to 71 mmHg (mean : 39) and PR from 0.6 to 4 units (mean : 1.79). A very strons correlation between RVDI and Qp/Qs was observed from equation Qp/Qs : 1.19 RVDI-0.43 with a standard error of 0.4. This relationship was not altered by either RVP or PR values, which also had no apparent correlation with RVDI. This study indicates that echocardiographic measurement of RVDI is a reliable and non-invasive method of evaluating the size of left to right shunts at the atrial level.     

Myxoid leiomyosarcoma of the left atrium: a rare malignancy of the heart and its comparison with atrial myxoma

Primary tumours of the heart are rare. The majority of these tumours are benign, with myxomas located in the left atrium being the most common form. Almost all malignant tumours are sarcomas and occur preferentially in the right side of the heart. An exception to this rule is leiomyosarcoma, a rare form of primary cardiac sarcoma that occurs predominantly in the left atrium, as does cardiac myxoma. The case of a 53-year-old woman who presented with symptoms of mitral valve stenosis and pulmonary hypertension is reported. Cardiac catheterization, angiography and echocardiography revealed a left atrial mass that was interpreted as atrial myxoma. At the time of operation, the myxoid appearance of the tumour mass further supported this assumption. The tumour, including a wide rim of atrial septum, was removed with cautery. Histopathological examination unexpectedly showed that the tumour was not an atrial myxoma but rather a myxoid variant of a primary leiomyosarcoma. Immunohistochemistry and electron microscopy confirmed the diagnosis. Local radiotherapy was considered but deemed contraindicated in view of the longstanding pulmonary hypertension. Two months after excision, a repeat echocardiogram indicated recurrence of tumour in the left atrium, and the patient died a few days later. The preferential left atrial location and the frequently myxoid appearance of primary leiomyosarcomas of the heart make it particularly difficult to differentiate them preoperatively from atrial myxomas. The authors recommend resection of all atrial myxoid tumours with a wide (at least 1 cm) margin, combined with intraoperative frozen section diagnosis, because complete surgical resection appears to correlate with prolonged survival in the few reported cases of atrial leiomyosarcomas. In cases of incomplete initial resection or local recurrence in the absence of metastatic disease, heart transplantation may be a valid option in appropriately selected patients.     

Hemodynamic correlates of late diastolic posterior motion of the aortic root

Motion of the posterior aortic root on echocardiography is related to left atrial volume change. Early diastolic posterior motion of the aortic root reflects both LA emptying and filling and has been measured as the atrial emptying index. To study late diastolic motion of the aortic root, we measured the slope of posterior motion of the aortic root after left atrial systole (following the P wave of the ECG) in 25 subjects without heart disease (Group 1), in 15 patients with left ventricular hypertrophy due to pressure overload (Group 2), and in 10 patients (Group 3) with mitral stenosis. The aortic root slope measured (mean ± SEM) 58.0 ± 1.9 mm./sec. in Group 1, 50.6 ± 4.5 mm./sec. in Group 2 (NS vs 1) and 28.8 ± 4.5 mm./sec. in Group 3, (p < 0.01 vs 1 or 2).In 16 patients (four in Group 1 and 12 in Group 2) studied at catheterization, an inverse correlation (r = ?0.74, p < 0.01) was found between the aortic root slope (over a range of 30 to 73 mm./sec.) and left ventricular late diastolic chamber stiffness measured with simultaneous left ventricular echo and high-fidelity pressure recordings. No correlation was found between this slope and either left atrial size, total aortic root excursion, left ventricular pressure pre “A” wave, height of the A wave, end-diastolic pressure, or the atrial contribution to left ventricular filling. Therefore, the aortic root slope in late diastole is decreased in mitral stenosis, and in the absence of mitral stenosis, it appears to be related to late diastolic properties of the left ventricle.     

Two decades of atrial tumour

We have reported 19 patients with atrial tumour. The long follow-up(5–19 years, mean 10 years) of the 17 patients with leftatrial myxoma has been described. No patient showed evidenceof recurrence of the tumour, although three patients have unexplainedshadows—probably artifactual—on echocardiography.The limitations ofechocardiography and importance of clinicalindicators are stressed. One patient had a rhabdomyosarcoma of the left atrium and diedone year after operation. Certain features differentiated thispatient from those with myxoma. It is concluded that true atrial myxoma does not metastasize.Reports in the literature of metastasizing left atrial myxomaprobably refer to malignant tumours simulating myxoma. Variationsfrom the typical clinical and haemodynamic picture of atrialmyxoma should arouse suspicion of malignancy. Careful microscopicexamination of the tumour is essential.     

M-mode echocardiography in constrictive pericarditis

M-mode echocardiograms from 40 patients with proven constrictive pericarditis and 40 subjects without evidence of cardiac disease were reviewed for features previously described in constrictive pericarditis. In this large series, no single feature of the M-mode echocardiogram could be considered diagnostic, although a pattern of normal left ventricular size and systolic function, mild left atrial dilation, flattened diastolic left ventricular posterior wall motion and abnormal septal motion was found in most patients. It is concluded that the M-mode echocardiogram can provide findings suggestive of constrictive pericarditis but must be used in conjunction with hemodynamic and other studies to establish the diagnosis.     

Atrial electromechanical sequence in normal subjects and patients with DDD pacemakers.

OBJECTIVE--To assess the effect of right atrial appendage pacing on atrial electromechanical interrelations in patients with DDD pacemakers. DESIGN--Prospective study by M mode echocardiogram, Doppler echocardiogram, and apexcardiogram, along with electrocardiogram and phonocardiogram. SETTING--Tertiary cardiac referral centre. PATIENTS--20 patients with DDD pacemakers and 20 age matched normal controls. RESULTS--Age, RR interval, atrial size, left ventricular size, and fractional shortening were similar in the two groups. Atrial electromechanical delay (the time from the onset of P wave or atrial pacing spike on ECG to the onset of atrial contraction on M mode echogram) was 68 (SD 7) ms at the lateral site of right atrium, 82 (9) ms at the central fibrous body, 93 (11) ms at the lateral site of left atrium in normals. In patients with DDD pacing, however, this delay increased to 85 (22) ms, 117 (23) ms, and 138 (25) ms respectively (all P < 0.01). Interatrial mechanical delay (the time from the onset of right atrial motion to the onset of the left) increased from 25 (6) ms in normal controls to 53 (18) ms in patients (P < 0.01). Intra-atrial mechanical dispersion (the time from the earliest to the latest onset of regional atrial motion around the atrioventricular ring) in the right atrium increased from 6 (2) ms in normals to 19 (2) ms in patients (P < 0.01), but it remained unchanged in the left atrium (6 (2) ms in normal controls v 7 (2) ms in patients, P > 0.05). Peak atrial shortening rate was not different between the two groups. Differences of atrial electromechanical activity between the two groups were also reflected on Doppler echocardiogram and apexcardiogram. CONCLUSIONS--Right atrial appendage pacing disturbs the normal coordinate sequence of right atrial mechanical activity and leads to a striking and variable increase in intra-atrial conduction time as well as in interatrial conduction time. Left atrial contraction remains synchronous although the timing of the start of its contraction was delayed. These values can be determined in individual patients to allow optimal setting of DDD pacemakers.     

Contrast echocardiography of right atrial mass due to hepatocellular carcinoma

We describe one patient suffering from hepatocellular carcinoma who presented with a right atrial metastatic tumour as a result of invasion of the inferior vena cava and extension into the right atrium. Two-dimensional echocardiography disclosed the right atrium tumour and SonoVue contrast agent echocardiography was employed to assess the local extension of the mass and to exclude an important obstruction due to a mass in the right ventricular inflow. Surgical management in the presence of metastatic right atrial tumour thrombus is described in the literature with poor results and this type of treatment should be reserved only for selected cases in which acute and severe cardiovascular distress due to obstruction of right ventricular inflow is present.