May

I 554

Brief Communications

American

Heart

1991
Journal

REFERENCES

1. Hales CA, Johnson

RA. Pulmonary
thromboembolism
and
nonthromboembolic
pulmonary
vascular
disease.
In: Eagle
KA, Haber E, DeSanctis
RW, Austen
WG. eds. Practice
of
cardiology.
2nd ed. Boston/Toronto:
Little;
Brown
& Company, 19891299-301.
2. Lvnch
J. et al. Incidence
of shunting.
Am J Cardiol
1984:
53:1478.
paradoxical
embolism
from atria1
3. Nelessen U, et al. Pending
thrombus:
correct diagnosis
by transesophageal
echo and prevention
by surgery.
J Am Co11 Cardiol
1985;5:1002-4.
4. Higgins
JR, et al. Diagnosis
of paradoxical
embolism
with
contrast
echocardiography.
AM HEART J 1984;107:375-7.
5. Loscalzo J. Paradoxical
embolism:
clinical presentation,
diagnostic strategies,
and therapeutic
options. AM HEART J 1986;
112:141-5.
6. Kitabataki
A, et al. Noninvasive
evaluation
of pulmonary
hypertension
by a pulsed Doppler
technique.
Circulation
1983;
68:302-g.
Fig.

Left ventricular myxoma discovered

incidentally by echocardiography

1. Parasternal

long-axis

view

showing

left ventricuLA, Left

lar massin the left ventricular outflow tract.

atrium; OT, left ventricular outflow tract.

David Wrisley, MD, Joel Rosenberg,MD,

Alessandro Giambartolomei, MD, Isaac Levy, MD,
Carol Turiello, RN, RDMS, and
Thomas Antonini, RPA.
Syracuse

and Liverpool,

N.Y.

Cardiac myxomas occur rarely, but are the most frequently

observed primary tumors of the heart1 The left atrium is
the most commonsite of occurrence,with a three- to fourfold predominanceover the right atrium.2 Incidence in the
left and right ventricles is similar, with approximately
2.5% to 4% of all myxomas occurring in each.ip2 A female
predominance is seenfor myxomas in general and for left
ventricular (LV) tumors in particular.2 LV myxomas occur
in a younger age group overall than myxomas in other
chambers2In this brief report, we describea young woman
who wasfound during routine echocardiographyto have
a mobile LV massthat was proved histologically to be a
myxoma.
A 25-year-old white womanwasreferred for an echocardiogram becauseof a heart murmur. Her heart was structurally normal except for the presenceof a bilobate, homogeneous,mobile masswithin the LV cavity (Fig. 1). This
appeared to be attached by a broad baseto the anterolatera1wall just distal to the mitral anulus. No involvement
of the mitral apparatus nor papillary musclewasapparent.
The massapproachedthe aortic valve during eachsystole,
but no significant flow abnormalities weredemonstratedby
either pulsedor continuous wave Doppler analysis.Shewas
admitted to St. JosephsHospital Health Center for further
evaluation and therapy. On being questioned, sherecalled
From the Departments
of Medicine and Surgery, SUNY Health Science
Center and St. Josephs Hospital Health Center, Syracuse; and North Medical Cardiovascular
Group, Liverpool.
Reprint requests: David Wrisley, MD, 5100 Taft Rd., Suite 26, Liverpool,
NY 13088.
414127852

Fig.
ration
outflow

2. Transesophagealview showing bilobate configuof the

tract;

LA, Left atrium;

RV, right ventricle.

mass.

OT, left ventricular

recent episodesof transient peripheral visual loss; in the

left eye in January 1990 and in the right eye in February
1990. No other localized or systemic symptoms had occurred. Other than a gradeII/VI systolic ejection murmur,
the physical examination was normal. Screening blood
studies,chest roentgenogram,electrocardiogram,and computed tomographic scanof the chest were normal. On the
secondday following
admission,
she was taken
to the operating room. Following induction of general anesthesia,
transesophagealechocardiography (TEE) was performed
to further assess
the masssattachments and to verify lack
of involvement of the mitral valve and its associatedstructures. The findings from the transthoracic study were confirmed (Fig. 2). No additional tumors were observedin any
cardiac chamber. A median sternotomy was done, the patient was placed on cardiopulmonary bypass, and cardioplegia was achieved. Ventriculotomy was performed

Volume

121

Number

Brief Communications

Fig.

3.

Immediate

post resection

appearance

of the operative

1555

specimen.

between the left anterior descending coronary artery and

its first diagonal branch. The tumor was visualized on the
free wall of the left ventricle and was resected with a cuff
of normal endocardium
(Fig. 3). On subsequent histologic
analysis, typical features of myxoma were demonstrated.
This patient presents several elements of note. Of incidental interest, no systolic murmur was heard following
surgery, suggesting that the tumor had caused some flow
disturbance
even though this was not evident symptomatically, nor was it seen on Doppler flow analysis. Simulation
of aortic stenosis by LV myxoma has been described
previously.3 Of more significance for this patient, her tumor
was discovered
incidentally,
during a routine murmur
evaluation. Of 16 patients with LV myxoma described in
1977,2 seven had died, most of embolic complications,
and
another 16-year-old subject had been left with a permanent
neurologic deficit. The mean age ( i SD) of the 16 patients
was 26 it 14 years; their range of ages was 11 to 50 years.
To the best of our knowledge, this is the first report of
an LV myxoma for which TEE was employed to help plan
the operative approach. This is important
for clarifying a
tumors site of attachment
and to check possible involvement of other structures that might influence the operative procedure. Additionally,
it has been pointed out that
myxomas occasionally
occur multifocally,4, 5 and additional tumors should be sought in all patients with
myxomas. The superior imaging quality of TEE compared
with transthoracic
echocardiography
should enhance both
of these elements of preoperative
assessment. Finally, it
has been reported that myxomas may recur either locally
or at sites different from the original location.5, 6 Periodic
postoperative
echocardiographic
evaluation should be routine for patients with LV myxomas, as well as for those
whose original tumors occurred in other cardiac chambers.

Primary cardiac tumors are uncommon with an autopsy

incidence ranging from 0.001 to 0.33 7%.le4 Most of these
tumors are benign. Of the benign tumors approximately
30.5% to 50% are myxomas. % 3 Myxomas are usually seen
with obstructive, thromboembolic,
or constitutional
signs
and symptoms. Signs and symptoms are usually correlated
with size and pedunculation.4
Before 1952 these tumors
were universally discovered at autopsy or incidentally
on

REFERENCES

From

1. McAllister

HA. Primary
tumors
and cysts of the heart and
pericardium.
In: Harvey
WP, ed. Current
problems
in cardiology. Chicago:
Year Book Medical
Publishers,
Inc, 1979.

2. Meller J, Teichholz
LE, Pichard
AD, Matta R, Litwol R, Herman MV. Left ventricular
myxoma;
echocardiographic
diagnosis and review of the literature.
Am J Med 1977;63:816-23.
A. Harriaan
P. Ponvic
AD. Left ventricular
3. Rosenzweig
myxoma
simulating
a&tic
stenosis.
AM HEART
J 1989;117:
962-3.

4. Abramowitz

5.

6.

R, Majdan
JF, Plzah LF, Beger BC. Two-dimensional echocardiographic
diagnosis
of separate
myxomas
of
both the left atrium
and left ventricle.
Am J Cardiol
1984;53:379-80.
Martin
LW, Wasserman
AG, Goldstein
H, Steinberg
JS, Mills
M, Katz RJ. Multiple
cardiac myxomas
with multiple
recurrence: unusual presentation
of a benign
tumor. Ann Thorac
Surg 1987;44:77-8.
Pavlides
GS, Levin RN, Hauser AM. Left ventricular
recurrence of a resected
left atria1 myxoma.
AM HEART J 1989;
117:1390-l.

Asymptomatic giant right atrial myxoma:

Role of transesophageal
echocardiography
in management
Sean V. Lyons,* MD, James McCord,
Stephen Smith, MD. Detroit, Mich.

the Henry

Ford

MD, and

Hospital.

*Reprint
requests:
Sean V. Lyons,
MD, Department
of Cardiology,
Ford Hospital,
2799 W. Grand Blvd., Detroit,
MI 48202.
4/4/27669.

Henry