Mitral Valve Fluttering*
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An Echocardiographic Feature of Left Atrial Myxoma David A. Ciraulo, M.D.
A patient with crescendo angina and severe tbree-vessel coronary disease had a left atrial myxoma fonnd incidentally and which w. removed d1J$g coronary bypass surgery. Preoperative echoc:ardiogram revealed only coarse diastolic mitral valve f1nttering without other echocardiographic features of left atrial myxoma. Postoperative echocardiogram showed disappearance of mitral valve fluttering. The isolated finding of dlastoUc mitral valve fluttering by echocardiography may be associated with occult left atrial myxoma.
L
eft atrial myxoma is an unusual cardiac lesion which may cause serious complications and yet is potentially curable. ·The echocardiographic features of left atrial myxoma have been well described, and in the majority of cases, left atrial myxoma can be diagnosed with confidence by echocardiography.' In a small percentage of cases, however, even a carefully performed echocardiographic examination may fail to reveal the presence of an echo-dense mass representing the myxoma. The following report describes a patient undergoing coronary bypass surgery for crescendo angina and triple-vessel coronary artery disease. Left atrial myxoma was found at the time of surgery. A preoperative echocardiogram failed to identify the left atrial tumor mass, but demonstrated diastolic Buttering of the mitral valve.
FiGURE
1. Preoperative echocardiogram, January 1, 1978.
( Left): Aortic valve and left atrium with no sign of left atrial tumor mass. (Right) : Mitral valve with coarse diastolic fluttering of anterior leaflet (arrow) . Posterior leaflet fluttering is apparent on other echocardiographic sections.
Jar performance and high-grade stenosis of the proximal anterior descending, right and circumflex coronary arteries. Because of continued anginal pains while she was resting in
bed, the patient was referred on an urgent basis for coronary bypass surgery which was performed on the following day. On
CASE REPoRT
This 68-year old woman was admitted to Daniel Freeman Hospital on January 9, 1978 with a history of chest pains of increasing frequency and severity over the previous two months and a diagnosis of unstable angina pectoris. She had a history of hypertension, but no other major medical problems. Physical examination on admission was unremarkable. Laboratory studies, including complete blood count, electrolytes, biochemical panel and cardiac enzyme analyses, were within normal limits. Electrocardiogram demonstrated ST-T wave changes; the chest x-ray film was unremarkable. On the day following admission, the patient had an echocardiographic examination (Fig 1) which was interpreted as showing only left atrial enlargement and coarse diastolic fluttering of the anterior and posterior leaflets of the mitral valve. The patient underwent left heart catheterization and coronary angiography on the same day. The findings were: normal left ventrien·From the Department of Cardiology, Daniel Freeman Hospital, Inglewood, California. llef,rint requests: Dr. Ciraulo, 323 North Prairie, Inglewood,
CQUfomia 90301
CHEST, 76: 1, JULY, 1979
1 FiGURE
2
2. Left atrial myxoma (gross specimen).
MITRAL VALVE FLUTIERING 95
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FIGtlRE 3. Postoperative echoeardiogram, June 2, 1978. ( Left) : Aortic valve and left atrium. (lUght) : Mitral valve with disappearance of diastolic fluttering. opening the pericardium at surgery, a prominent mass was immediately felt in the left atrium, and was removed . On pathologic examination (Fig 2) the tumor was a myxoma measusing 51 X 4" X 4 em and weighing 35 grams. A review of the preoperative angiogram showed no evidence of the atrial tumor. The patient's postoperative course was unremarkable, and she returned home on January 28, 1978. She continued to improve. On June 2, 1978, as an outpatient, she had echocardiography performed (Fig 3), which again showed mild left atrial enlargement, but with the disappearance of previously noted diastolic fluttering of the mitral valve. DISCUSSION
In the case presented, the left atrial myxoma was found incidentally during surgery for coronary revascularization. There were no preoperative clinical signs or symptoms to arouse suspicion of an atrial myxoma. Echocardiography performed with multiple gain settings by the standard technique revealed neither the presence of a left atrial echo-dense mass nor flattening of the E-F slope of the anterior mitral leaflet. The absence of these findings is probably due to the fact that this atrial myxoma was relatively small in size and non-prolapsing.
96 DAVID A. CIRAULO
Bodenheimer et al2 have shown experimentally that smaller, non-prolapsing left atrial tumors may fail to appear as dense echoes above the anterior mitral leaflet in diastole and may fail to show flattening of the anterior mitral leaflet E-F slope. Potts et ala have presented clinical data confirming the fact that smaller left atrial myxomas produce less prominent echo-dense masses above the mitral valve in diastole and may fail to cause flattening of the mitral E-F slope. Sung et al' have indicated that nonprolapsing left atrial myxomas may not be seen on standard echocardiographic examinations, and special echocardiographic approaches to the left atrium may be necessary to identify an occult tumor mass. In the case presented, the presence of diastolic mitral valve fluttering on the preoperative echocardiogram with normal mitral valve motion on the postoperative echocardiogram is evidence that diastolic mitral valve fluttering can be related to left atrial myxoma. The echocardiographic appearance of diastolic mitral valve fluttering associated with left atrial myxoma previously has been reported by Clark. 6 This phenomenon, which is probably related to turbulent blood flow around the left atrial tumor toward the mitral leaflets, has not been widely recognized as a sign of left atrial myxoma. The case presented here is the first report in which diastolic mitral valve fluttering was the only echocardiographic sign of left atrial myxoma. The recognition of diastolic mitral valve fluttering as an echocardiographic feature of left atrial myxoma may make this an important clue to the presense of nonprolapsing, smaller atrial myxomas which may be difBcult to diagnose otherwise echocardiographically. ACKNOWLEOOMENT: I am indebted to Harvey Feigenbaum, M.D., for his critical review of this case and encouragement. I am also indebted to Irene Arnold, Emily Woerner, Katherine Koebel, Susan O'Dnseoll, and Robert Schwarte for their technical assistance.
1 WoHe SB, Popp RL, Feigenbaum H: Diagnosis of atrial tumors by ultrasound. Circulation 39 :615-622, 1969 2 Bodenheimer MM, Moscovitz HL, Pantazopoulos J et al: Echocardiographic features of experimental left atrial tumor. Am Heart J 88 :615-620, 1974 3 Potts JL, Johnson LW, Eich RB, et al: Varied manifestations of left atrial myxoma and the relationship of eehocardiographic patterns of tumor size. Chest 68 :781-784, 1975 4 Sung RL, Ghahramani An, Mallon SM, et at: Hemodynamic features of prolapsing and non-prolapsing left atrial myxoma. Circulation 51:342-349, 1975 5 Clark RD : Case Studies in Echocardiography. Philadelphia, WB Saunders, 1977 p 76
CHEST, 76: 1, JULY, 1979
=.-
-
--
An Echocardiographic Feature of Left Atrial Myxoma David A. Ciraulo, M.D.
A patient with crescendo angina and severe tbree-vessel coronary disease had a left atrial myxoma fonnd incidentally and which w. removed d1J$g coronary bypass surgery. Preoperative echoc:ardiogram revealed only coarse diastolic mitral valve f1nttering without other echocardiographic features of left atrial myxoma. Postoperative echocardiogram showed disappearance of mitral valve fluttering. The isolated finding of dlastoUc mitral valve fluttering by echocardiography may be associated with occult left atrial myxoma.
L
eft atrial myxoma is an unusual cardiac lesion which may cause serious complications and yet is potentially curable. ·The echocardiographic features of left atrial myxoma have been well described, and in the majority of cases, left atrial myxoma can be diagnosed with confidence by echocardiography.' In a small percentage of cases, however, even a carefully performed echocardiographic examination may fail to reveal the presence of an echo-dense mass representing the myxoma. The following report describes a patient undergoing coronary bypass surgery for crescendo angina and triple-vessel coronary artery disease. Left atrial myxoma was found at the time of surgery. A preoperative echocardiogram failed to identify the left atrial tumor mass, but demonstrated diastolic Buttering of the mitral valve.
FiGURE
1. Preoperative echocardiogram, January 1, 1978.
( Left): Aortic valve and left atrium with no sign of left atrial tumor mass. (Right) : Mitral valve with coarse diastolic fluttering of anterior leaflet (arrow) . Posterior leaflet fluttering is apparent on other echocardiographic sections.
Jar performance and high-grade stenosis of the proximal anterior descending, right and circumflex coronary arteries. Because of continued anginal pains while she was resting in
bed, the patient was referred on an urgent basis for coronary bypass surgery which was performed on the following day. On
CASE REPoRT
This 68-year old woman was admitted to Daniel Freeman Hospital on January 9, 1978 with a history of chest pains of increasing frequency and severity over the previous two months and a diagnosis of unstable angina pectoris. She had a history of hypertension, but no other major medical problems. Physical examination on admission was unremarkable. Laboratory studies, including complete blood count, electrolytes, biochemical panel and cardiac enzyme analyses, were within normal limits. Electrocardiogram demonstrated ST-T wave changes; the chest x-ray film was unremarkable. On the day following admission, the patient had an echocardiographic examination (Fig 1) which was interpreted as showing only left atrial enlargement and coarse diastolic fluttering of the anterior and posterior leaflets of the mitral valve. The patient underwent left heart catheterization and coronary angiography on the same day. The findings were: normal left ventrien·From the Department of Cardiology, Daniel Freeman Hospital, Inglewood, California. llef,rint requests: Dr. Ciraulo, 323 North Prairie, Inglewood,
CQUfomia 90301
CHEST, 76: 1, JULY, 1979
1 FiGURE
2
2. Left atrial myxoma (gross specimen).
MITRAL VALVE FLUTIERING 95
---
_ _
--
-
..' ..
.
.' .
~ "
,,~ ~ .
"".
" :~~
. ~ :" '"
' :\ ~
.
:~:
,
~~"".\o"
•
~~ ,'"~'~ . ,": . "" ..
.
."
,. ..
.
JI--
. .. . . . . .
"'~t·
t
.
~~
_
5
..'
=
::c_-::.
~
.t, -:
,
: ,; to
...
~ ,
. .' ~ - ' ; ' "
~
.',
~!!!!~'"
~ ~ =' i',~ .~-:':;'
. '
".
~ ~ .~ :Qt:.eifl:iC'" . ~ ~ : ...~ ~ ~
"'~.
FIGtlRE 3. Postoperative echoeardiogram, June 2, 1978. ( Left) : Aortic valve and left atrium. (lUght) : Mitral valve with disappearance of diastolic fluttering. opening the pericardium at surgery, a prominent mass was immediately felt in the left atrium, and was removed . On pathologic examination (Fig 2) the tumor was a myxoma measusing 51 X 4" X 4 em and weighing 35 grams. A review of the preoperative angiogram showed no evidence of the atrial tumor. The patient's postoperative course was unremarkable, and she returned home on January 28, 1978. She continued to improve. On June 2, 1978, as an outpatient, she had echocardiography performed (Fig 3), which again showed mild left atrial enlargement, but with the disappearance of previously noted diastolic fluttering of the mitral valve. DISCUSSION
In the case presented, the left atrial myxoma was found incidentally during surgery for coronary revascularization. There were no preoperative clinical signs or symptoms to arouse suspicion of an atrial myxoma. Echocardiography performed with multiple gain settings by the standard technique revealed neither the presence of a left atrial echo-dense mass nor flattening of the E-F slope of the anterior mitral leaflet. The absence of these findings is probably due to the fact that this atrial myxoma was relatively small in size and non-prolapsing.
96 DAVID A. CIRAULO
Bodenheimer et al2 have shown experimentally that smaller, non-prolapsing left atrial tumors may fail to appear as dense echoes above the anterior mitral leaflet in diastole and may fail to show flattening of the anterior mitral leaflet E-F slope. Potts et ala have presented clinical data confirming the fact that smaller left atrial myxomas produce less prominent echo-dense masses above the mitral valve in diastole and may fail to cause flattening of the mitral E-F slope. Sung et al' have indicated that nonprolapsing left atrial myxomas may not be seen on standard echocardiographic examinations, and special echocardiographic approaches to the left atrium may be necessary to identify an occult tumor mass. In the case presented, the presence of diastolic mitral valve fluttering on the preoperative echocardiogram with normal mitral valve motion on the postoperative echocardiogram is evidence that diastolic mitral valve fluttering can be related to left atrial myxoma. The echocardiographic appearance of diastolic mitral valve fluttering associated with left atrial myxoma previously has been reported by Clark. 6 This phenomenon, which is probably related to turbulent blood flow around the left atrial tumor toward the mitral leaflets, has not been widely recognized as a sign of left atrial myxoma. The case presented here is the first report in which diastolic mitral valve fluttering was the only echocardiographic sign of left atrial myxoma. The recognition of diastolic mitral valve fluttering as an echocardiographic feature of left atrial myxoma may make this an important clue to the presense of nonprolapsing, smaller atrial myxomas which may be difBcult to diagnose otherwise echocardiographically. ACKNOWLEOOMENT: I am indebted to Harvey Feigenbaum, M.D., for his critical review of this case and encouragement. I am also indebted to Irene Arnold, Emily Woerner, Katherine Koebel, Susan O'Dnseoll, and Robert Schwarte for their technical assistance.
1 WoHe SB, Popp RL, Feigenbaum H: Diagnosis of atrial tumors by ultrasound. Circulation 39 :615-622, 1969 2 Bodenheimer MM, Moscovitz HL, Pantazopoulos J et al: Echocardiographic features of experimental left atrial tumor. Am Heart J 88 :615-620, 1974 3 Potts JL, Johnson LW, Eich RB, et al: Varied manifestations of left atrial myxoma and the relationship of eehocardiographic patterns of tumor size. Chest 68 :781-784, 1975 4 Sung RL, Ghahramani An, Mallon SM, et at: Hemodynamic features of prolapsing and non-prolapsing left atrial myxoma. Circulation 51:342-349, 1975 5 Clark RD : Case Studies in Echocardiography. Philadelphia, WB Saunders, 1977 p 76
CHEST, 76: 1, JULY, 1979
