The protective effect of mitral stenosis on the embolization of a free-floating left atrial myxoma.

Mitral stenosis associated with free left atrial myxoma is very rare. A free myxoma is life-threatening when incarcerated in the mitral orifice or if embolization of the whole tumor occurs. We report a case of a female patient with moderate mitral stenosis and a detached left atrial myxoma. The myxoma was spherical, solid and smooth-surfaced. Mitral stenosis prevented the exit of the tumor from the left atrium and a possible fatal outcome. The tumor was surgically removed and mitral commissurotomy was successfully performed. Histological analysis confirmed the diagnosis of myxoma.     

Transesophageal Pulsed Doppler Echocardiographic Study of Systolic Flow Velocity Patterns of the Pulmonary Vein in Patients with Atrial Fibrillation

We recorded pulmonary venous flow velocity in 27 patients with atrial fibrillation using transesophageal pulsed Doppler echocardiography to investigate the cycle length-dependent characteristics and background of early systolic reversal and second systolic forward waves. The study group consisted of 15 patients with mitral stenosis, 5 patients with left atrial myxoma, and 7 patients without underlying organic heart disease; they were compared with 20 normal controls in sinus rhythm. The mean pulmonary capillary wedge pressure was significantly greater in patients with mitral stenosis and left atrial myxoma than in normal controls and in patients with isolated atrial fibrillation. The mean peak velocity of the early systolic reversal wave was also significantly greater in patients with mitral stenosis and left atrial myxoma than in patients with isolated atrial fibrillation. The mean peak velocity of the second systolic forward wave was significantly lower in patients with mitral stenosis and left atrial myxoma than in controls and in patients with isolated atrial fibrillation. The preceding RR interval had significant negative correlations with the peak early systolic reversal velocity, left atrial pressure during closure of the mitral valve, and peak V wave height of the pulmonary capillary wedge pressure in patients with mitral stenosis and left atrial myxoma. In the same patient groups, the preceding RR interval had significant positive correlations with the peak second systolic forward velocity and amplitudes of the mitral annular and interatrial septal motions during ventricular systole. The variations in the peak velocities of the early systolic reversal and second systolic forward waves with the preceding RR interval were smaller in patients with more severe mitral stenosis. In conclusion, early systolic reversal waves of the pulmonary venous flow velocity reflect left atrial pressure, and the second systolic forward waves reflect left atrial filling. Both velocities vary with disease conditions or preceding RR intervals in atrial fibrillation.     

A patient with rheumatic mitral stenosis and an atrial myxoma.

A 34-year-old woman with exertional dyspnoea and clinical diagnosis of mitral stenosis underwent echocardiographic evaluation. Moderate to severe rheumatic mitral stenosis was confirmed but an unsuspected mass lesion in the dilated left atrium attached to inter-atrial septum in fossa ovalis region was found. Although the attachment was in favour of myxoma, it was difficult to differentiate with certainty between left atrial myxoma and thrombus. Warfarin was prescribed but after 1 year the mass lesion remained unchanged. Both the severity of the mitral stenosis and the presence of the mass lesion led to our decision to proceed with surgery. Pathology showed typical histology of a myxoma.     

Giant left atrial myxoma mimicking severe mitral valve stenosis

We report a case of giant left atrial myxoma in a young patient with clinical manifestation as congestive heart failure attributable to severe mitral valve stenosis. An early clinical and echocardiographic diagnosis was performed and the patient had an optimal outcome with surgery treatment.     

Pulsed Doppler transmitral flow in a case of myxoma of the left atrium

This work deals with transmitral flow studied with Range Gate Pulsed Doppler Echocardiography in a 73 year old man affected by left atrial myxoma. The dominant clinical picture was pleural effusion and dyspnoea. Neither syncope nor systemic emboli were reported. Echocardiography (TM and 2D) and surgical inspection showed a large moving tumor connected to the interatrial septum with a short stalk. The histological examination gave evidence of myxoma. Range Gate Pulsed Doppler Echocardiography, using the apical four chamber view, was performed with the sample volume between the mitral leaflets and tumor. Peak velocities were normal, indicating no diastolic a-v gradient, probably the size of the tumor interfered with left atrial filling. The flow between the anterior leaflet and tumor was only protodiastolic: the myxoma leaning on the leaflet just after the opening stopped the blood stream. The flow between the posterior leaflet and tumor was variable, with single or multiple velocity peaks (early, middle and end diastole): this was probably caused by the intermittent obstruction of the a-v ostium. These data agree with the variability of the auscultation in the left atrial myxoma and show that the flow pattern is different from that of mitral stenosis.     

The transesophageal echocardiographic diagnosis of left atrial myxoma simulating a left atrial thrombus in the setting of mitral stenosis.

We report a case of left atrial myxoma simulating a thrombus on transthoracic echocardiography, but correctly diagnosed using transesophageal echocardiography. As this tumor is usually fatal unless surgically resected, a correct diagnosis is essential. Myxomas which do not prolapse between the mitral valve leaflets and coexist with mitral stenosis may be difficult to diagnose accurately using transthoracic echocardiography. The advantages of transesophageal compared with transthoracic echocardiography in the diagnosis of nonclassical left atrial myxoma are discussed.     

Mitral valve fluttering; an echocardiographic feature of left atrial myxoma.

A patient with crescendo angina and severe three-vessel coronary disease had a left atrial myxoma found incidentally and which was removed during coronary bypass surgery. Preoperative echocardiogram revealed only coarse diastolic mitral valve fluttering without other echocardiographic features of left atrial myxoma. Postoperative echocardiogram showed disappearance of mitral valve fluttering. The isolated finding of diastolic mitral valve fluttering by echocardiography may be associated with occult left atrial myxoma.     

Mitral valve annular dilatation caused by left atrial myxoma

We report a case of mitral valve annular dilatation caused by a large left atrial myxoma. A 69-year-old woman presented in pulmonary oedema. She was found to have a large left atrial myxoma prolapsing into the left ventricle in diastole causing severe functional mitral stenosis. At operation, the myxoma was completely excised from its attachment to the atrial septum. The mitral valve looked anatomically normal but the mitral annulus was dilated. The intraoperative Trans Oesophageal Echocardiogram (TOE) on weaning from cardiopulmonary bypass confirmed a dilated mitral annulus with moderate mitral regurgitation (MR). We elected not to place an annuloplasty ring in anticipation of improvement with postoperative remodelling. However, mitral regurgitation worsened after discharge becoming moderately severe and remains so after 1 year follow-up despite optimal medical treatment. This case suggests that annular dilatation can result from mechanical dilatation by a large left atrial myxoma. Intraoperative mitral valve annuloplasty should be considered in the presence of moderate MR as postoperative remodelling does not occur.     

Right atrial trans-septal approach for left atrial myxomas--nine-year experience

OBJECTIVE: In this single-center study we reviewed our experience with left atrial myxomas occurring over the past 9 years. METHODS: Sixty-three patients underwent excision of cardiac myxomas between 1995 and 2004. Of these, 56 patients (32 females and 24 males) had left atrial (LA) myxoma. The mean age was 37.80+12.97 years (range 3.5-67 years). Echocardiography was the only diagnostic evaluation done. The preferred approach for resection was right atrial trans-septal. Annual echocardiographic evaluation was undertaken following surgery. Follow-up is current and available in all the survivors (range 4 months-9 years). RESULTS: Clinically 75% of the LA myxomas simulated mitral stenosis. The symptoms were present for 2-6 months before operation. Most (86%) LA myxomas were attached to the fossa ovalis. Few (14%) originated from the LA wall, mitral valve annulus and anterior mitral leaflet. One patient succumbed to low cardiac output and another died of massive embolic stroke following surgery. There were no late deaths. Two patients (3.7%) developed left hemiparesis after operation but recovered completely. There was one (1.9%) recurrence 3 years after surgery. Atrial fibrillation occurred in one patient. Mitral insufficiency which was seen in two (3.7%) patients prior to surgery subsided following excision of the tumor. Postoperatively 94% patients remained without symptoms. CONCLUSION: Owing to the risk of valvular obstruction or embolization early surgery is indicated. Right atrial trans-septal approach is safe and easy. Most patients are asymptomatic following surgery. A yearly follow-up is essential.     

Varied manifestations of left atrial myxoma and the relationship of echocardiographic patterns of tumor size.

Four cases of left atrial myxoma with varied clinical manifestations were diagnosed with echocardiographic studies prior to cardiac catheterization and surgery. The unusual clinical features include Raynaud's phenomenon and intermittent claudication. The echocardiographic features of the atrial myxoma appear to be related to tumor size. Systematic echocardiographic evaluation of patients with mitral valvular disease and systemic and cerebral vascular insufficiency will undoubtedly increase the positive diagnostic results in patients with atrial myxomas. Removal of these tumors results in normalization of the echocardiographic pattern.     

Echocardiography in Left Atrial Myxoma: Relation to the Findings in Mitral Stenosis

Summary: A pre-operative diagnosis of left atrial myxoma was made in a 49-year-old woman in whom echo-cardiograms suggested mitral stenosis but the physical signs were not in accord with this diagnosis. The findings on echocardiography were compared with observations in 15 normal subjects and 50 consecutive patients with mitral stenosis coming to valvotomy. Correlations between angiocardiograms and echograms in this patient contribute to an understanding of the mechanisms responsible for the altered mitral valve leaflet reflections invariably found with echocardiography in patients with mitral stenosis.     

Obstructive mitral vegetations in bacterial endocarditis. Disappearance after migration as an embolism

An unusual form of mitral valve endocarditis was observed on echocardiography. A 49 year old female with well tolerated mitral stenosis and mild aortic incompetence contracted staphylococcal endocarditis. Pulmonary venous hypertension developed and the diastolic murmur increased. The echocardiogramme showed voluminous vegetations obstructing the stenosed mitral orifice in diastole, simulating a left atrial myxoma. An acute ischaemic episode of the lower limb occurred under antibiotic therapy. A voluminous fibrino-cruoric infected embolus was extracted from the iliac artery and a second echocardiogramme showed the intra mitral mass to have disappeared. Concurrently, the diastolic murmur decreased and the signs of intolerance disappeared. When the infective process seemed to have been controlled, the patient died suddenly. Post-mortem examination showed fresh mitral endocardial lesions and renal and splenic infarcts. Five cases of mitral obstruction by vegetations have been previously reported, three of which had echocardiographic studies. The echocardiographic image is stereotyped and resembles a myxoma wedged in the mitral orifice but without the intra atrial mass. This type of mitral obstruction complicated moderate mitral stenosis in all cases. Regression of the echographic appearances of valvular vegetations has been reported in rare cases, but we were unable to find another case of embolism of vegetations reducing the valvular obstruction.     

Severity of mitral regurgitation may be underestimated in the presence of a left atrial myxoma

It is well known that mobile or large left atrial myxoma may lead to valve obstruction and insufficiency, and affect transmitral valve flow. The case is reported of a 47-year-old woman with severe mitral regurgitation (MR) and huge left atrial myxoma (6?4?3 cm). Preoperatively, the MR appeared related to the myxoma and was classified as moderate. Following extirpation of the myxoma, intraoperative transesophageal echocardiography (TEE) revealed a severe mitral regurgitant jet. After mitral valve repair by ring implantation, the MR was reduced to minor insufficiency. Hence, a large atrial tumor may mask the severity of concomitant unrelated MR in routine echocardiography. Intraoperative TEE helped in assessing correct mitral valve function after tumor extirpation. Preoperative echocardiography should focus on mitral valve dysfunction in order to separate tumor-related and -unrelated valvular pathologies.     

Rapid progression of primary cardiac leiomyosarcoma with obstruction of the left ventricular outflow tract and mitral stenosis

We report a 73-year-old woman with primary cardiac leiomyosarcoma in the left atrium and ventricle. The tumor progressed very rapidly for 2 months after initial clinical evaluation. Obstruction of the left ventricular outflow tract and mitral stenosis were induced by the tumor. Urgent surgical resection was performed because she had cardiogenic shock due to paroxysmal atrial fibrillation. We could not resect the tumor completely because of severe invasion. She refused postoperative chemotherapy and radiotherapy, and died suddenly at home 89 days after surgery. To our knowledge, this is the first observation of mitral stenosis concomitant with obstruction of the left ventricular outflow tract in a patient with primary cardiac leiomyosarcoma.     

Right Atrial Thrombus Mimicking a Myxoma: Synergism of Hormonal Contraceptives and Antiphospholipid Antibodies

Cardiac thrombus, the most common intracardiac mass, is typically seen in the left side of the heart in the presence of atrial fibrillation, mitral stenosis, or impaired global wall motion. Right atrial thrombus, which is rarer, is usually associated with central venous catheter placement or pulmonary embolism. We present the case of a 24-year-old woman with a history of mitral valve prolapse who presented with fatigue and palpitations. Echocardiograms and cardiac magnetic resonance images revealed a right atrial mass compatible with a myxoma. However, after surgical excision of this and a second mass discovered intraoperatively, pathologic evaluation confirmed organized thrombus rather than myxoma.The patient''s only risk factor was her use of oral contraceptive pills. Test results for hypercoagulable disorders revealed the presence of antiphosphatidylserine, an uncommon antiphospholipid antibody. The patient stopped taking the contraceptive. This case suggests the need to examine further the role of antiphosphatidylserine antibodies in the diagnosis of antiphospholipid syndrome.     

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.     

Large atrial myxoma causing mitral obstruction and severe pulmonary hypertension

Myxoma is the most common type of cardiac tumor, accounting for 30-50% of all primary cardiac tumors. Clinically, patients usually present with at least one of the classic triad of obstructive cardiac, embolic, and constitutional signs. The case is reported of a large atrial myxoma in the left atrium which caused mitral valve obstruction, leading to severe pulmonary hypertension and right heart failure, mimicking rheumatic mitral stenosis. Postoperatively, a fall occurred in the patient's pulmonary artery pressure and she showed clinical improvement.     

Cystic left atrium myxoma--a rare case report

Myxoma is the most common primary tumor of heart. The typical picture of myxoma under echocardiography is a solid, dense echo mass and left atrium is the most common site to find it. The cystic form of myxoma is vary rare. We report a patient who received echocardiographic examination under impression of mitral valve stenosis. A multilobulated cystic mass which was like a hydatid cyst was found in the left atrium and atrioventricular flow was affected by this mass. After tumor resection, myxoma with internal hemorrhage was proved by pathology. No further recurrent myxoma was found during follow-up echocardiographic examination.     

Primary cardiac sarcoma mimicking benign myxoma: a case report

A 53-year-old woman presented with a primary cardiac sarcoma mimicking benign myxoma manifesting as progressive heart failure. Transesophageal echocardiography disclosed two separate tumors in the left atrium which appeared just like myxoma, except for the origin and multiple growth profile. Three separate tumors were identified during the operation arising from the posterior wall of the left atrium, mitral valve orifice and left atrial free wall. The histological diagnosis was malignant undifferentiated sarcoma. Six months later, she noticed dyspnea and arm numbness due to local recurrence of cardiac tumor and brain metastasis. She died suddenly 6 months after the surgery during admission. The clinical and echocardiographic findings are crucial to discriminate malignant cardiac tumors from benign myxoma. Rapidly progressive clinical course, multiple tumor growth and non-septal attachment of the tumor all suggest a malignant profile of the primary cardiac tumors. Careful and precise preoperative evaluation, including echocardiographic survey of the tumor origin and multiple growth profile, are essential to identify malignant cardiac tumor.     

Early systolic notch in the apexcardiogram in mitral stenosis

An early systolic notch on the upstroke of the apexcardiogram (ACG) has previously been reported to occur in mobile left atrial myxoma but has not been noted in valvular mitral stenosis. It has therefore been considered a useful diagnostic sign for myxoma. We report four patients with mitral valve stenosis who had an early systolic notch in the ACG. Myxoma was excluded by catheterization and/or surgery. We feel that the notch is not specific for myxoma and that its finding should be interpreted with caution.