Imaging in cardiology T. Tak
Figure 1. Transoesophageal image of a left atrial myxma which was not large enough to prolapse tbrougb the mitral orificc during ventricular diastok. AX Horizontal view showing the tumour in close proximity to the interatrial septum. B. Horizontal view showing a the eft attial myxoma (indicated by arrow).
small superimposed thrombus on
Role of echocardlography In diagoss of left atrlal myxoma A 76-year-old female with a negative cardiovascular history presented with symptoms oftransient ischaemic attack (TIA). She denied constitutional symptoms prior to presentation. Physical examination was unremarkable. Subsequent neurological workup included CT scanning of the head; carotid duplex ultrasonography, blood chemistries, chest x-ray and 12-lead ECG were all essentially within normal limits.
Two-dimensional echocardiography was performed to rule out an intracardiac source of embolism. This was a technically difficult study but showed an unidentifiable mass in the left atrium. Saline contrast injection was negative for intracardiac shunt. To fiuther delineate the intracardiac abnormality, transoesophageal echocardiography (TEE) was performed. This revealed a spherical left atrial mass measuring 2.5x2.5 cm. attached to the interatrial septum (figure IA). A T. Tak.
Department of Cardiology, Marshfield Clinic, Marshfield. Wisconsin 54449, USA. E-mail: [email protected]
34
small sessile structure superimposed on this mass was also observed (figure IB). The presumptive diagnosis was that of an atrial myxoma with superimposed thrombus. In view of the patient's history, it was decided to excise the left atrial mass. On surgery, a small thrombus was seen superimposed on the myxoma. The mass along with a portion ofthe interatrial septum were excised and a dacron patch was used to close the defect at the level of the fossa ovalis. Pathological anatomical findings were consistent with an atrial myxoma with superimposed thrombus.
DIscussion Cardiac myxomas are the most common cardiac tumours and frequently located in the left atrium. They have the potential for embolisation. Tumour embolisation of the central nervous system constitutes about 50% ofembolic events. Microscopic examination of myxomas has shown that they are composed of mucopolysaccharide myxoid matrix in which polygonal cells and occult blood vessels are embedded. Channels often filled with red blood cells communicate from the surface to deep within the tumour, although fibrin, erythrocytes and organised thrombi may also be present on the surface (figure 1C). In the patient presented, a thrombus was superimposed on the
Netherlands Heart Journal, Volume 11, Number 1, January 2003
Imaging in cardiology
embolisation, atrial myxoma should be suspected if the embolism is neurological or recurrent. The proper treatment of intracardiac myxomas is operative resection because no medical treatment is available to treat the tumour. Fortunately, recurrences of atrial myxomas are rare and if they do occur, it is usually within a four-year period following surgery. U Refernces 1
2 3 4
C. Pathologic anatomy of specimen under low magnification showing presence offibrin (indicated by arrow).
myxoma and probably resulted in an embolic event. The presence of the thrombus superimposed on the myxoma was confirmed both by macroscopic and microscopic examination. Although two-dimensional echocardiography was useful in diagnosing the mass in the left atrium, TEE was confirmatory in regard to the tumour size, location and its attachment to the interatrial septum. This underscores the importance of performing TEE when real-time two-dimensional findings are equivocal or if clinical suspicion of an intracardiac source of embolism is high. In systemic
Netherlands Heart Journal, Volume 11, Number 1, January 2003
5
McAllister HA, Fenoglio JJ. Tumours ofthe heart and pericardium. Washington D.C. Armed Forces; 1978. Steinmetz EF, Calanchini PR, Aguilar J. Left atrial myxoma as a neurological problem: a case report and review. Stroke 1973;4:4518. Reynen K Cardiac Myxomas. NEnglJMed 1996;333:1610-7. Ha J-W, Kang W-C, Chung N. Echocardiographic and morphologic characteristics of left atrial myxoma and their relationship to systemic embolism. AmJCardiol 1999;83:1579-82. Silverman J, Olwin JS, Graettinger JS. Cardiac myxomas with systemic embolisation. Circulation 1962;26: 99.
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one to two pages at the most) to Mediselect bv, Editorial Office Netherlands Heart Journal, PO Box 63, 3830 AB Leusden, the Netherlands. This section is edited by M.J.M. Cramer and W. Jaarsma.
35
Figure 1. Transoesophageal image of a left atrial myxma which was not large enough to prolapse tbrougb the mitral orificc during ventricular diastok. AX Horizontal view showing the tumour in close proximity to the interatrial septum. B. Horizontal view showing a the eft attial myxoma (indicated by arrow).
small superimposed thrombus on
Role of echocardlography In diagoss of left atrlal myxoma A 76-year-old female with a negative cardiovascular history presented with symptoms oftransient ischaemic attack (TIA). She denied constitutional symptoms prior to presentation. Physical examination was unremarkable. Subsequent neurological workup included CT scanning of the head; carotid duplex ultrasonography, blood chemistries, chest x-ray and 12-lead ECG were all essentially within normal limits.
Two-dimensional echocardiography was performed to rule out an intracardiac source of embolism. This was a technically difficult study but showed an unidentifiable mass in the left atrium. Saline contrast injection was negative for intracardiac shunt. To fiuther delineate the intracardiac abnormality, transoesophageal echocardiography (TEE) was performed. This revealed a spherical left atrial mass measuring 2.5x2.5 cm. attached to the interatrial septum (figure IA). A T. Tak.
Department of Cardiology, Marshfield Clinic, Marshfield. Wisconsin 54449, USA. E-mail: [email protected]
34
small sessile structure superimposed on this mass was also observed (figure IB). The presumptive diagnosis was that of an atrial myxoma with superimposed thrombus. In view of the patient's history, it was decided to excise the left atrial mass. On surgery, a small thrombus was seen superimposed on the myxoma. The mass along with a portion ofthe interatrial septum were excised and a dacron patch was used to close the defect at the level of the fossa ovalis. Pathological anatomical findings were consistent with an atrial myxoma with superimposed thrombus.
DIscussion Cardiac myxomas are the most common cardiac tumours and frequently located in the left atrium. They have the potential for embolisation. Tumour embolisation of the central nervous system constitutes about 50% ofembolic events. Microscopic examination of myxomas has shown that they are composed of mucopolysaccharide myxoid matrix in which polygonal cells and occult blood vessels are embedded. Channels often filled with red blood cells communicate from the surface to deep within the tumour, although fibrin, erythrocytes and organised thrombi may also be present on the surface (figure 1C). In the patient presented, a thrombus was superimposed on the
Netherlands Heart Journal, Volume 11, Number 1, January 2003
Imaging in cardiology
embolisation, atrial myxoma should be suspected if the embolism is neurological or recurrent. The proper treatment of intracardiac myxomas is operative resection because no medical treatment is available to treat the tumour. Fortunately, recurrences of atrial myxomas are rare and if they do occur, it is usually within a four-year period following surgery. U Refernces 1
2 3 4
C. Pathologic anatomy of specimen under low magnification showing presence offibrin (indicated by arrow).
myxoma and probably resulted in an embolic event. The presence of the thrombus superimposed on the myxoma was confirmed both by macroscopic and microscopic examination. Although two-dimensional echocardiography was useful in diagnosing the mass in the left atrium, TEE was confirmatory in regard to the tumour size, location and its attachment to the interatrial septum. This underscores the importance of performing TEE when real-time two-dimensional findings are equivocal or if clinical suspicion of an intracardiac source of embolism is high. In systemic
Netherlands Heart Journal, Volume 11, Number 1, January 2003
5
McAllister HA, Fenoglio JJ. Tumours ofthe heart and pericardium. Washington D.C. Armed Forces; 1978. Steinmetz EF, Calanchini PR, Aguilar J. Left atrial myxoma as a neurological problem: a case report and review. Stroke 1973;4:4518. Reynen K Cardiac Myxomas. NEnglJMed 1996;333:1610-7. Ha J-W, Kang W-C, Chung N. Echocardiographic and morphologic characteristics of left atrial myxoma and their relationship to systemic embolism. AmJCardiol 1999;83:1579-82. Silverman J, Olwin JS, Graettinger JS. Cardiac myxomas with systemic embolisation. Circulation 1962;26: 99.
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one to two pages at the most) to Mediselect bv, Editorial Office Netherlands Heart Journal, PO Box 63, 3830 AB Leusden, the Netherlands. This section is edited by M.J.M. Cramer and W. Jaarsma.
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