Echocardiography of an operated case of a myxoma of the tricuspid valve

The case of a 6 year old child with a tricuspid valve myxoma is presented. Early diagnosis by echocardiography, confirmed by angiography, resulted in surgical cure before any symptoms appeared. This is the only reported echocardiographic study of a myxoma inserted on the tricuspid valve found in a review of the literature of 6 cases of right ventricular myxoma. The tricuspid valves were found to be thickened and prolapsed into the right atrium. The amplitude of excursion of the anterior leaflet was greatly increased, its mass projecting into the right ventricular outflow tract in diastole and remaining there until the end of right ventricular ejection. The echocardiographic signs localising the precise origin of the tumor in the tricuspid valve are developed. The differential diagnosis with right atrial myxoma prolapsing into the ventricular cavity, benign and malignant right ventricular tumours and tricuspid valve vegetations is discussed. The precision of the diagnostic information obtained by echocardiography suggests that angiography may not be essential any longer, especially when the risk of embolisation and acute obstruction are taken into consideration.     

Echocardiographic features of right ventricular outflow tumor prolapsing into the pulmonary artery

The echocardiographic features of a tumor in the right ventricular outflow tract that prolapsed into the pulmonary artery during systole are described. The patient was a 19 year old woman who presented clinically with bacterial endocarditis involving a mildly stenotic pulmonary valve. An echocardiogram, obtained to evaluate the pulmonary valve for bacterial vegetations, showed abnormal echoes throughout the cardiac cycle; they suggested a tumor mass in the right ventricular outflow tract in front of the pulmonary valve with possible extension into the pulmonary artery during systole. Additional tumor echoes confined to diastole were recorded in front of the aortic root and the tricuspid valve. These features were further elucidated with a computer-generated two dimensional cineechocardiogram that clearly showed a portion of the tumor mass passing beyond the position of the pulmonary valve into the main pulmonary artery in systole and returning into the right ventricular outflow in diastole. At surgery, a large myxoma was found in the right ventricular outflow tract with a polypoid extension that projected into the pulmonary artery in systole and contained a fibrinous vegetation at its tip. The left cusp of the pulmonary valve was normal, but the other two leaflets showed evidence of endocarditis.     

Massive right atrial myxoma: an unusual presentation in an elderly patient

Primary heart tumors are rare with an estimated incidence ranging 0.0017-0.19%. Myxoma is the most prevalent primary heart tumor. The right atrium is an unusual location, occurring only in the 15-20% of myxoma cases. We describe the case of a massive right atrial myxoma causing right ventricular inflow and tricuspid valve obstruction. The tumor was detected by echocardiography and confirmed by abdomen-thoracic tomography. It was resected along with a section of tricuspid septal leaflet, followed by primary repair. In 2-year follow-up the patient is asymptomatic.     

心脏黏液瘤的外科诊治分析

目的 探讨心脏黏液瘤的外科治疗的临床要素.方法 回顾性分析92例心脏黏液瘤患者的临床资料并复习相关文献.结果 1997年至2012年收治经手术治疗和病理证实的心脏黏液瘤患者92例,男性38例,女性54例,年龄4～67岁,病史1个月至5年;其中左房黏液瘤80例,右房黏液瘤6例,双心房黏液瘤2例,右心室黏液瘤3例,左心室黏液瘤1例.术前均由超声心动图确诊,在全麻体外循环下手术摘除黏液瘤.同期行二尖瓣成形、二尖瓣置换术各3例,三尖瓣成形6例.术前诊断率100％.所有患者均治愈出院.87例经随访,随访时间3个月至5年2个月,复发1例.结论 心脏黏液瘤是最常见的心脏肿瘤,手术治疗效果确切.把握手术时机、避免肿瘤脱落引起栓塞等并发症的发生是手术成功的重要因素.超声心动图对诊断及随访均具有重要意义.     

Evaluation of secondary tricuspid regurgitation by intraoperative epicardial pulsed Doppler echocardiography

Since 1985, we have evaluated secondary tricuspid regurgitation associated with acquired mitral valve disease in patients undergoing open mitral surgery by intraoperative epicardial two-dimensional and pulsed Doppler echocardiography. We found intraoperative pulsed Doppler echocardiography to be a sensitive, safe technique allowing surgeons to evaluate the severity of tricuspid regurgitation intraoperatively, even in critically ill patients who cannot afford preoperative cardiac catheterization. To assess the severity of tricuspid regurgitation intraoperatively, the transducer was placed directly on the right atrium. The ultrasound beam was transmitted into the right atrium at right angles to the tricuspid valve orifice to record intraoperative four-chamber two-dimensional echocardiograms, which were used to detect the sites of eight sample volumes, one in the right ventricle and seven in the right atrium, for pulsed Doppler echocardiography. The pulsed Doppler signals were recorded in each sample volume before and after cardiac procedures. The pansystolic abnormal signals lasting from tricuspid valve closure to the subsequent opening and consisting of components moving away from the tricuspid valve were interpreted as tricuspid regurgitant flows. Without operative correction of the tricuspid valve, secondary tricuspid regurgitation can resolve following mitral valve surgery alone. However, to our knowledge, there are no published reports of objective findings of intraoperative changes of secondary tricuspid regurgitation. Here we present the unique intraoperative pulsed Doppler echocardiographic features of tricuspid regurgitation before and after cardiac procedures. A 30-year-old woman with preoperative diagnosis of aortic regurgitation, mitral stenosis and severe tricuspid regurgitation underwent aortic and mitral valve replacement. The intraoperative pulsed Doppler echocardiograms recorded after pericardiotomy and before cannulation of the heart showed tricuspid regurgitant flow signal in all of the seven sample volumes in the right atrium, which was interpreted as severe tricuspid regurgitation. After surgical procedures, no regurgitant flow from the tricuspid orifice to the right atrium was detected in the eight sample volumes. This suggested that preoperative secondary tricuspid regurgitation improves without operative procedures for the tricuspid valve. All intraoperative echocardiographic procedures were performed within 5 min, and no arrhythmias or other complications related to this technique were noted. Epicardial pulsed Doppler echocardiography is helpful in assessing tricuspid valve function of patients undergoing mitral valve surgery bef     

Calcified mass in the right atrium extending into the inferior vena cava with pulmonary artery embolization. Typical or atypical myxoma?

Cardiac masses are divided into neoplastic and non-neoplastic. They usually represent a diagnostic challenge given their relative rarity, their infrequent symptoms, and the overall difficulty with dynamic imaging of the heart. While echocardiography is useful in the initial evaluation of a suspected mass, cardiac magnetic resonance (CMR) imaging is the best imaging modality to characterize cardiac tumors due to its superior tissue characterization and its higher contrast resolution. For neoplastic, primary cardiac tumors are rare (0.05%). Atrial myxoma is the most common cardiac (50%) mass. About 75%-80% of myxoma are seen in the left atrium. Atypical myxoma is a term describing myxoma arising in other nonleft atrial locations. 20%-25% myxomas arise from the right atrium and 5% or less from the ventricles. We present a case of a 59-year-old female patient presenting with severe dyspnea. Her chest noncontrast CT showed a calcified mass lesion in the right atrium extending into the inferior vena cava. She underwent cardiac MRI for better tissue characterization. The cardiac MRI revealed a very irregular, highly spiculated, heavily calcified, heterogeneous, and nonenhancing lesion within the right atrium extending into the inferior vena cava. Via dynamic imaging, no evidence of mobile components was present. Via T1, T2 along with pre- and postcontrast imaging, the mass was confirmed to be calcified without a fibrotic component or evidence of thrombus. The above findings raised the possibility of atypical myxoma.     

Delayed postoperative cardiac tamponade mimicking severe tricuspid valve stenosis

A patient developed acute, severe hemodynamic deterioration five days after an aortic valve replacement. Cardiac catheterization revealed a markedly elevated right atrial pressure but a normal right ventricular end-diastolic pressure. Angiography revealed an extrinsic mass causing compression of the right atrium and the tricuspid anulus. A large clot overlying the right atrium and ventricle was found at emergency surgery. Postoperative cardiac tamponade may result in an atypical hemodynamic presentation when there is selective compression of one chamber or of a valve anulus.     

Hepatocellular carcinoma invading the right atrium: clinical, echographic and angiographic study

The authors report the case of a 54 year old woman suffering from hepatocellular carcinoma with tumor growth into right hepatic vein, inferior vena cava and right atrium. On cardiac examination, a pansystolic bruit and a diastolic rumble were audible at the tricuspid focus. Diagnosis was confirmed by inferior vena cavography and two-dimensional echocardiography, which demonstrated a large mobile mass in the right atrium moving to and fro through the tricuspid valve. This case report emphasizes the value of routine cardiac examination during the course of hepatocellular carcinoma.     

Hepatocellular carcinoma with right atrial extension in a young patient with congenitally unguarded tricuspid orifice

We report a case of a young female patient with congenitally unguarded tricuspid orifice and underdeveloped pulmonary valve leaflets, who had developed severe right-sided congestive heart failure and cardiac cirrhosis early in life. She was admitted to our hospital with deterioration of dyspnea and abdominal tenderness. Hepatocellular carcinoma was diagnosed on the basis of computed tomography findings, high plasma alpha-fetoprotein levels and evidence of chronic hepatitis B viral infection. Transthoracic echocardiogram revealed a mass into the right atrium, considered to be an extension of the tumor.     

Giant right atrial myxoma leading to cardiac arrest in an infant

We present the case of a three-month-old infant with a giant right atrial myxoma obstructing the tricuspid valve, who following haemodynamic deterioration and cardiac arrest, was operated upon as an emergency. On echocardiogram, there was a mass attached to the tricuspid annulus, in close proximity to the septal leaflet, with dimensions of 16.6 × 12.5 mm. The mass was prolapsing through the tricuspid valve into the right ventricle and obstructing the inflow. While preparing for surgery, cardiac arrest occurred, so the patient underwent an emergency operation under cardiopulmonary resuscitation. The mass was excised without damaging the tricuspid valve and the conduction system. Histologically, the mass consisted of a myxoid matrix with scatted globoid and star-shaped myxoma cells. The patient stayed 15 days in the intensive care unit and was discharged home on the 20th day postoperatively. Although accepted as a benign tumour, a myxoma can display an aggressive clinical course in infants. In centres where cardiac operations cannot be performed, these patients need to be transferred to cardiac centres as soon as possible. Whatever the clinical presentation, we advocate immediate surgical extirpation of the tumour in order to avoid any unpredictable consequences in its clinical course.     

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.     

Kidney tumour mimicking cardiac mass

The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis between a primary cardiac tumour (with myxoma being the most frequent), invasion of an extracardiac tumour, vegetations on the tricuspid valve, and an atrial thrombus. We describe the case of a patient who was admitted to our service with a diagnosis of suspected myxoma based on the chance transthoracic echocardiographic discovery of a right atrial mass. A transesophageal echocardiogram showed the process to be extracardiac, and magnetic resonance imaging showed it to originate at the renal level extending via the inferior vena cava to the right atrium. Tumour extension with thrombosis of the vena cava is a relatively frequent complication of renal carcinoma, but only exceptionally does it reach the right atrium. It is also exceptional that this was a chance finding in an asymptomatic patient.     

Un volumineux myxome de l’oreillette droite révélé par une insuffisance cardiaque droite

Right atrial myxoma is a heart benignant tumor characterized by an important clinical polymorphism. We report a case of a 30-year-old female with a diagnosis of a big right atrial myxoma. The diagnosis has been done by transthoracic echocardiography which showed an important tumorous mass in the right atrium. It was moving, inhomogeneous and takes over the whole of right atrium cavity. The surgical excision of the tumor has been done under extracorporal circulation. The patient died after a second intervention for tricuspid failure.     

Right ventricular myxoma

We recently treated a patient with right ventricular myxoma and a clinical picture of pulmonary embolism and tricuspid valve obstruction who had successful removal of the tumor through the tricuspid valve via a right atriotomy.     

An unusual echocardiographic finding in a ruptured sinus of Valsalva aneurysm

A patient with a ruptured sinus of Valsalva aneurysm (RSVA) demonstrated an unusual two-dimensional echocardiographic manifestation of this entity. A discrete mass of echoes, appearing attached to a posterior leaflet of the tricuspid valve, moved to and fro into the right ventricle during diastole and into the right atrium in systole. This echocardiographic appearance mimics a vegetation of the tricuspid valve, a flail tricuspid leaflet, a right atrial myxoma or a pedunculated right atrial thrombus. Therefore, the differential diagnosis of this echocardiographic finding should include RSVA in addition to the above mentioned disorders.     

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.     

Massive right-sided cardiac thrombosis in Chagas' heart disease without left ventricular dysfunction

A 63-year-old woman with the diagnosis of mega-oesophagus secondary to chronic Chagas' disease and no past cardiac history was referred for cardiac evaluation. The resting ECG showed right bundle-branch block, whereas a 2-D echocardiogram revealed marked right ventricular dilatation with hypokinesia, right atrial dilatation, normal pulmonary artery pressure, and normal left ventricular ejection fraction. A large, irregularly shaped mass, arising from the right atrium and protruding into the right ventricle through the tricuspid valve, with several different bizarre forms inside the right atrium during systole and/or diastole was seen on 2-D echocardiogram. Therefore, massive right-sided thrombosis can be detected in Chagas' disease patients with no overt right- and left-sided ventricular failure.     

Primary atrial heart tumors--a review of 21 cases

Between 1978 and 1986, atrial heart tumors were found in 21 of our patients, all of them subsequently underwent surgery. Pathological-histological examination in 20 patients confirmed the diagnosis of a myxoma; the one remaining case was a female patient with primary cardiogenic osteosarcoma. Of the 20 patients, 15 (75%) were females; in four female patients (20%) the tumor was localized in the right atrium. The main symptoms and findings were elevated erythrocyte sedimentation rates (80%), stress-induced dyspnea or paroxysmal dyspnea (71% resp.), and diastolic mitral or tricuspid murmurs (62%). The patient with osteosarcoma died of cachexia on the basis of generalized diffuse metastases. One female patient with a preoperative history of severe left ventricular impairment on the basis of dilative cardiomyopathy died 5 weeks after surgery. Relapse of atrial myxoma has not yet occurred during follow-up since 1978.     

Mitral and tricuspid lesions associated with polypoid atrial tumors, including myxoma

The related atrioventricular valves in 11 instances of polypoid atrial tumors were examined grossly and histologically. Nine of the tumors involved the left atrium and, of these, seven were myxomas. The two right atrial tumors were myxomas.

Histologically evident lesions of the mitral valve were present in seven of the nine left atrial tumors. The most common change consisted of fibrous thickening of the endocardium in the angle between the left atrium and posterior mitral leaflet and fibrous thickening of the atrial surfaces of the leaflet. Less common changes were a fibrous thickening of the chordae and of the left ventricular mural endocardium in relation to chordae inserting into the posterior leaflet. The changes described were also evident at gross examination in two of the nine cases with left atrial tumors.

In the two cases of right atrial myxoma, both showed fibrous thickening of the atrial surfaces of the tricuspid leaflets; one also exhibited fibrous thickening of the right ventricular endocardium beneath the septal leaflet of the tricuspid valve.

The lesions described are considered responses to the effects of friction by the tumor upon the surfaces involved. It is significant that grossly evident lesions may evolve from this rubbing action.     

Two dimensional echocardiography in evaluation of right atrial masses: five cases in pediatric patients

Five unusual cases of a right atrial mass in children are described to illustrate the very valuable contribution that two dimensional echocardiographic examinations can bring to both the initial diagnosis and the subsequent management of patients with these findings. One patient had a large benign hemangioendothelioma of the right atrium. Two infants had extension of a Wilms' tumor from the kidney by way of the inferior vena cava to the right atrium. A fourth patient, an 8 year old girl, had no cardiac disease, and manifested Staphylococcus aureus endocarditis of the tricuspid valve with a large pedunculated mass and subsequent pulmonary embolus. A fifth patient, a premature infant with a central hyperalimentation catheter in the right atrium, had a large thrombus on the catheter that was successfully eradicated with urokinase-induced thrombolysis. Two dimensional echocardiography provides real time imaging of the entire right atrium, interatrial septum, inferior and superior venae cavae and tricuspid orifice and hence is valuable in the diagnosis and management of these clinical problems.