Cysts in left atrial myxomas identified by transesophageal cross-sectional echocardiography

Atypical cardiac myxomas: a clinicopathologic analysis and their comparison to 64 typical myxomas

INTRODUCTION

Myxomas are the most common among the primary cardiac neoplasms, seen mainly in adult population, and are typically attached to the interatrial septum, on the left side. Myxomas arising from other sites are designated as "atypical myxomas." In this article, we describe the clinicopathologic features of 28 such lesions, resected in 20 patients.

METHODS

A 15-year study (1995-2009) of all cardiac myxomas, received as surgical excisions in our institution, was performed. Atypical myxomas were selected on the basis of their atypical sites of origin, and a systematic review and comparison of their clinicopathologic features with all typical myxomas excised during the same period were done.

RESULTS

Among a total of 84 patients who had undergone cardiac myxoma excisions in this 15-year duration, 64 patients had typical myxomas, while atypical myxomas (30 tumors) were diagnosed in 20 patients (23.8%). None of them had a family history of similar symptoms. There were six children. In the atypical subset, there were 12 males and eight females; the mean age of diagnosis was 33.7 years. This demography differed from the typical myxoma group where there were more females than males and the mean age of diagnosis being 40.8 years. The symptoms of dyspnea, episodic chest pain, and palpitation were common in both cohorts of patients, and all showed a mass lesion with varying degrees of valvular regurgitation and obstruction on echocardiography. Five of the 20 patients with atypical myxomas had multifocal or multicentric tumors. Grossly, like typical myxomas, the atypical ones also exhibited solid and papillary patterns with the usual histological features. Four patients had recurrence of the disease.

CONCLUSIONS

Atypical myxomas are rare lesions having clinical and pathological features, not entirely different from those of typical myxomas. With the advent of modern diagnostics, it is now imperative to do genetic studies and screen the relatives of patients having atypical myxomas to rule out additional occult familial cases as they are now known to occur more in this "atypical" group.

Star in the heart

In a 50 year old woman, transthoracic echocardiography showed a left atrial mass. Transoesophageal echocardiography delineated its attachment. Additionally, cystic spaces were seen arranged concentrically in the shape of a star in the centre of the tumour. Surgical excision followed. Histopathological examination confirmed myxoma with areas of haemorrhage and necrosis. This case highlights the acoustic property of myxomas in a rare and beautiful manner and emphasises the superior transoesophageal imaging of myxomas.

CT and MR imaging of benign primary cardiac neoplasms with echocardiographic correlation

Benign primary cardiac neoplasms are rare but may cause significant morbidity and mortality. However, they are usually treatable and can often be diagnosed with echocardiography, computed tomography (CT), or magnetic resonance (MR) imaging. Myxomas typically arise from the interatrial septum from a narrow base of attachment. Fibroelastomas are easily detected at echocardiography as small, mobile masses attached to valves by a short pedicle. Cardiac fibromas manifest as a large, noncontractile, solid mass in a ventricular wall at echocardiography and as a homogeneous mass with soft-tissue attenuation at CT. They are usually homogeneous and hypointense on T2-weighted MR images and isointense relative to muscle on T1-weighted images. Paragangliomas usually appear as large, echogenic left atrial masses at echocardiography and as circumscribed, heterogeneous masses with low attenuation at CT. These tumors are usually markedly hyperintense on T2-weighted MR images and iso- or hypointense relative to myocardium on T1-weighted images. Cardiac lipomas manifest at CT as homogeneous, low-attenuation masses in a cardiac chamber or in the pericardial space and demonstrate homogeneous increased signal intensity that decreases with fat-saturated sequences at T1-weighted MR imaging. Cardiac lymphangiomas manifest as cystic masses at echocardiography and typically demonstrate increased signal intensity at T1- and T2-weighted MR imaging. Familiarity with these imaging features and with the relative effectiveness of these modalities is essential for prompt diagnosis and effective treatment.

Differentiation of intracardiac tumors and thrombi by echocardiographic tissue characterization: comparison of an artificial neural network and human observers

The feasibility of classifying ultrasound images of intracardiac tumors and thrombi with a neural network-based algorithm was compared with the performance of experienced echocardiographers. The neural network used statistical descriptors of the apparent echocardiographic texture of the masses, and the blinded echocardiographers were given photographic prints of enlarged regions of interest without clinical data. The network classified 66% of the images correctly and the echocardiographers, 83%. The network and echocardiographers agreed in 88% of the images. Human observers usually base their classification of intracardiac masses on clinical data. The echocardiographic texture of tumors is quantitatively different from that of thrombi. This difference can be recognized by a neural network and potentially be useful in assisting with the diagnosis when clinical clues are insufficient.

Comparison of transthoracic and transesophageal echocardiography in the diagnosis of intracardiac tumors in adults

To compare transthoracic and transesophageal echocardiography in the diagnosis of intracardiac tumors, 17 patients (8 men and 9 women, aged 19 years to 67 years) whose intracardiac tumors were detected by echocardiography were studied in a 4-year period. Of these, 14 patients underwent cardiac surgery and 13 were proved to have tumors. There were 4 false-positive and 2 false-negative diagnoses by transthoracic echocardiography, but only one false-positive and no false-negative diagnosis by transesophageal echocardiography. The stalk of a myxoma was detected clearly in 5 of 11 patients by transthoracic echocardiography, whereas in 10 of 11 it was detected by transesophageal echocardiography. The detailed morphologic characteristics of the tumor, such as contour of the tumor, and the presence of cysts and calcification in the tumor, were seen more clearly with transesophageal echocardiography than with transthoracic echocardiography.

Diagnosis of right atrial mass lesions by transesophageal and transthoracic echocardiography

The echocardiographic findings by transesophageal and transthoracic techniques were compared in 16 patients with right atrial mass lesions diagnosed by transesophageal echocardiography. In only 8 of the 16 patients were the masses imaged by transthoracic echocardiography. Masses in the main body of the right atrium (three of five), as well as those associated with indwelling catheters and pacer wires (three of four) were more likely to be imaged by transthoracic echocardiography than masses in the right atrial appendage (zero of three) or in the superior or inferior vena cava (one of three). Associated masses in other cardiac chambers were detected by transthoracic echocardiography in three of six patients. Other features such as size, mobility, and site of attachment of right atrial masses in general were better defined by transesophageal echocardiography. Thus, patients with suspected right atrial masses should be investigated with transesophageal echocardiography.

Cardiac evaluation

Over the past decade there has been a dramatic, rapid development of new imaging modalities used in the evaluation of the cardiac patient. These newer techniques are frequently complex and specialized in their application and interpretation. Nonetheless, the prevalence of cardiac disease in the United States, and the wide application of these diagnostic tests, mandate that the well-rounded clinician has a basic understanding of the utility of these diagnostic modalities. Unfortunately, the burgeoning field of cardiac imaging seems at times to overshadow our most important basic diagnostic tools, namely, the history, physical exam, chest radiograph, and electrocardiogram (ECG). This review will attempt to impart a basic understanding of the newer cardiac diagnostic tests and their utility in various disease states. Emphasis on the importance of the basic clinical exam and the precise integration of specific diagnostic tests into the cardiac evaluation will be emphasized. The article will deliver a basic review of exercise treadmill testing, echocardiography, radionuclide imaging techniques, magnetic resonance imaging, and cardiac catheterization. It is hoped that this review will impart to the noncardiologist clinician a basic understanding of the cardiovascular diagnostic techniques so that an accurate, precise, cost-effective, efficient diagnostic plan for the patient with cardiovascular disease can be developed and applied.

The use of transoesophageal echocardiography for detecting early recurrence of atrial myxoma

A comparison between praecordial and transoesophageal cross-sectional echocardiography was undertaken in the follow-up of 14 patients who had previously undergone surgical excision of atrial myxoma. The mean interval between surgery and follow-up was 39 months. Evidence of recurrent tumour was seen in two patients by transoesophageal echocardiography but went undetected in one of these using the praecordial approach. Clear visualisation of the atria and interatrial septum was possible in all remaining cases using transoesophageal echocardiography and this allowed confident exclusion of tumour recurrence. Using praecordial echocardiography, technically inadequate studies meant that this was not possible in 4 patients. The significant late recurrence rate of excised atrial myxomas, emphasises the need for serial, postoperative echocardiographic studies. Praecordial echocardiography may be unreliable in the detection of recurrent atrial myxoma in its early stages and for this reason transoesophageal echocardiographic follow-up is justified in high risk patients.

Transesophageal echocardiography

Transesophageal echocardiography has provided a new acoustic window to the heart, the great vessels, and the mediastinum. It provides anatomical, functional hemodynamic, and blood flow information. High-quality visualization of left atrial appendage, thoracic aorta, atrial septum, and mitral valvular apparatus can be obtained readily. We discuss historical and technical aspects of transesophageal echocardiography, anatomical views, and major clinical indications for this procedure. These indications include intracardiac masses, thoracic aortic dissection, endocarditis, prosthetic and native cardiac valve function assessment, as well as its value in the detection of intracardiac source of systemic emboli. Furthermore, the role of transesophageal echocardiography in the assessment of coronary artery and congenital heart disease and as an intraoperative diagnostic and monitoring technique is discussed.

Transesophageal echocardiography and cardiac masses

Although transthoracic two-dimensional echocardiography has been a procedure of choice for diagnosing cardiac mass lesions, the advent of transesophageal echocardiography (TEE) provided better visualization of cardiac structures, especially those at a considerable depth from the chest wall, and lesions that involve the left atrial appendage. In this study, we examined the experience at our institution with TEE imaging of cardiac mass lesions (excluding valvular vegetations) from April 1988 to July 1990. TEE studies detected 83 lesions (in 80 patients), which we characterized by type and site: 46 left atrial, 16 right atrial, 7 left ventricular, 2 right ventricular, and 12 extracardiac mass lesions. Of the 46 left atrial lesions, 9 were tumors and 37 were thrombi that involved the body of the left atrium, the left atrial appendage, or both. Associated mitral valve disease, chronic atrial fibrillation, or spontaneous microcavitations were common. Of the 16 right atrial mass lesions, 4 were tumors and 12 were thrombi, including "string" thrombi characteristic of venous thromboembolism. Of the seven left ventricular mass lesions, six were thrombi and one was a papilloma. Of the 12 extracardiac mass lesions, 2 were pericardial cysts and the rest were solid lesions. TEE added new or important clinical information beyond that derived from transthoracic echocardiography in left atrial thrombi, right atrial masses, and extracardiac lesions and was assessed to have influenced the management of patients most in these areas also. TEE is a useful addition to transthoracic echocardiography for diagnosis and clarification of cardiac mass lesions in selected patients.

Transesophageal echocardiography: procedures and clinical application

In existence for more than a decade, transesophageal echocardiography has gained renewed interest because of technologic advances including high resolution transducers, multiple imaging planes and Doppler color flow mapping. The heart is imaged from within the esophagus with a gastroscope-mounted transducer, obviating technical difficulties encountered in transthoracic echocardiography. Transesophageal echocardiography is utilized intraoperatively to monitor patients undergoing open heart surgery or high risk cardiac patients undergoing noncardiac surgery. In the ambulatory patient, the procedure facilitates imaging of many structures (including the left atrium and appendage, mitral and aortic native and prosthetic valves and thoracic aorta), with better resolution than that obtained by routine transthoracic echocardiography. Technical aspects of transesophageal echocardiography as well as its indications and limitations are reviewed.

Atypical myxoma

We report the case of a 38-year-old woman with a large thin-walled cystic mass (6 x 5 x 4.5 cm) filled with arterial blood in the right atrium. The cystic mass with blood content was clearly delineated by transesophageal cross-sectional echocardiography and magnetic resonance imaging of the heart. At operation, a silver-whitish, smooth surfaced cystic mass was found attached to the free wall of the right atrium between the superior vena cava and the right atrial appendage with a broad base. Microscopically, the wall of the cyst was composed of stellate mesenchymal cells embedded within a myxoid matrix which was proved by alcian blue stain. To our knowledge, this type of cardiac myxoma has not been previously reported.

Spontaneous left atrial haematoma

We present a woman with paroxysmal atrial fibrillation and a mass in the left atrium. Cross-sectional echocardiography defined the lesion as cystic, while magnetic resonance imaging depicted it as a solid mass with areas of focal bleeding. Surgical resection showed a partially organized haematoma within the left atrial wall. The patient did well after surgery, although atrial fibrillation recurred. The presence of an atrial haematoma is rare, specially when spontaneous, and we stress the usefulness of magnetic resonance in reaching an aetiologic diagnosis.

Diagnosis of noninfective cardiac mass lesions by two-dimensional echocardiography. Comparison of the transthoracic and transesophageal approaches

This study was conducted in 46 patients with cardiac thrombi, 15 patients with atrial myxomas, and 32 patients with other cardiac or paracardiac tumors. Diagnoses were subsequently proven by surgery, autopsy, computed tomography, magnetic resonance imaging, or angiography in all patients. All patients underwent precordial and transesophageal two-dimensional echocardiography to assess the various mass detection rates. Atrial myxomas and predominantly left-sided cardiac tumors were identified by both echocardiographic techniques with comparable detection rates. Left ventricular apical thrombi were detected more frequently by precordial echocardiography. In contrast, transesophageal echocardiography was superior in visualizing left atrial appendage thrombi, small and flat thrombi in the left atrial cavity, thrombi and tumors in the superior vena cava, and masses attached to the right heart and the descending thoracic aorta. These data indicate that transesophageal echocardiography leads to a clinically relevant improvement of the diagnostic potential in patients in whom cardiac masses are suspected or have to be excluded in order to ensure the safety of clinical procedures.

Impact of transesophageal color flow Doppler echocardiography in current cardiology practice

Of 3,480 patients who were referred for cardiac ultrasound evaluation, 230 patients (6.6%) underwent transesophageal echocardiography because the transthoracic study was not feasible, technically inadequate, or provided insufficient diagnostic information for optimal patient management. There were 149 inpatients and 81 outpatients. The majority (182 patients, 79%) had aortic or mitral disorders. In 166 patients (72%), transesophageal echocardiography played a significant role in patient management. Transesophageal echocardiography was most useful in evaluating diseases of the aorta (dissection, root abscess, or aneurysm), mitral prosthesis, complications of endocarditis, left atrial appendage thrombi, and in determining the cause of mitral insufficiency. Transesophageal echocardiography was useful in the evaluation of critically ill patients and those with severe lung disease.

Myxoma with a left-to-left shunt and fistula

We present the case of a 68-year-old man with a peculiar coincidence of cardiac pathologic findings: a huge left atrial myxoma, mitral insufficiency, a high degree atrioventricular block and three-vessel disease. The myxoma was vascularized from a dilated sinus arteriosus branch, giving rise to neovascularization at the base of the tumor. Blood from the neovascularization gathered into a large cavern which fistulated into the left atrium, responsible for a left-to-left cardiac shunt.

Cavernous lymphohemangioendothelioma of the right atrium--a case report

The authors report a successful resection of a rare cystic tumor in the right atrium, discovered in an asymptomatic patient with atrial fibrillation. The cystic nature of the tumor was characterized by two-dimensional echocardiogram preoperatively. The site of attachment and movement of the tumor were clearly shown by cine computed tomography preoperatively. The tumor contained numerous endothelium-lined cavernous channels and groups of red blood cells. These features are distinctly different from those of other cystic tumors.

Detection of multiple cardiac papillary fibroelastomas using transesophageal echocardiography

Papillary fibroelastomas are rare, benign cardiac tumors that may be associated with embolization, angina, and sudden death. We report a case of multiple papillary fibroelastomas diagnosed during life by transesophageal echocardiography. Surgical resection during mitral valve replacement for rheumatic mitral stenosis prevented the development of any of the life-threatening complications sometimes associated with this tumor.

Transesophageal echocardiography

Two-dimensional transesophageal echocardiography generally has superior sensitivity and image quality compared with precordial echocardiography. Its unique anatomic perspective posterior to the heart often provides important clinical information not obtainable by other imaging approaches and technologies. It is particularly useful in the diagnosis of mitral valve disease, left atrial masses, endocarditis and its sequelae, and aortic dissections. It is also useful for examination of the left main coronary artery, left ventricular outflow tract, atrial and ventricular septa, and congenital defects. In addition to its application as a diagnostic tool in conscious patients, it can be employed intraoperatively to evaluate and guide surgical intervention. Detection of ventricular wall motion abnormalities by transesophageal echocardiography has been shown to be the most sensitive indicator of myocardial ischemia available in the clinical setting. It has potential for wide application for safely monitoring left ventricular function in patients in intensive care or under anesthesia.

Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications

The introduction of transesophageal echocardiography has provided a new acoustic window to the heart and mediastinum. High-quality images of certain cardiovascular structures [left atrial appendage, thoracic aorta, mitral valvular apparatus, and atrial septum] can be obtained readily (average examination, 15 to 20 minutes). In this article, we discuss the technique of image acquisition, image orientation, and anatomic validation. In addition, we describe our experience with the first 100 awake patients who underwent transesophageal echocardiography at our institution. The procedure was well accepted by the patients and associated with no major complications. The clinical indications for this procedure have included thoracic aortic dissection, prosthetic cardiac valve dysfunction, detection of an intracardiac source of embolism, endocarditis, cardiac and paracardiac masses, and mitral regurgitation. Transesophageal echocardiography also proved to be useful in assessment of critically ill patients in whom standard transthoracic echocardiographic images did not provide complete assessment. In these patients (who had extensive chest trauma, had undergone an operation, or were in an intensive-care unit), rapid assessment of the cardiovascular status at the bedside was possible with transesophageal echocardiography. On the basis of our initial experience, we conclude that transesophageal echocardiography complements standard two-dimensional Doppler and color flow examinations and will considerably improve the care of patients with cardiovascular disorders by providing high-quality unique images.

Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk

The incidence of left atrial spontaneous echo contrast was evaluated in 52 patients with isolated or predominant mitral valve stenosis (Group 1) and 70 other patients who had undergone mitral valve replacement (Group 2). All patients were studied by conventional transthoracic and transesophageal two-dimensional echocardiography. Spontaneous echo contrast could be visualized within the left atrium in 35 Group 1 patients (67.3%) (including 7 patients with sinus rhythm) and 26 Group 2 patients (37.1%) (all with atrial fibrillation). Patients with spontaneous echo contrast had a significantly larger left atrial diameter and a greater incidence of both left atrial thrombi and a history of arterial embolic episodes than did patients without spontaneous echo contrast. Association between spontaneous echo contrast and left atrial thrombi and a history of arterial embolization (considered individually or in combination) showed a high sensitivity and negative predictive value. It is concluded that spontaneous echo contrast is a helpful finding for identification of an increased thromboembolic risk in patients with mitral stenosis and after mitral valve replacement.

Unusual echocardiographic appearance of intracardiac thrombi in a patient with endomyocardial fibrosis

A five year old girl presented with a four month history of recurrent heart failure, which subsequently proved to be caused by endomyocardial fibrosis. There was no evidence of valvar disease. Echocardiography showed several echogenic masses with echolucent centres within the cardiac cavity. Histological examination showed that these masses were partly organised thrombus.

Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus

Thrombi located in the left atrial appendage are frequently not detected with conventional two-dimensional echocardiography. The transesophageal echocardiographic approach readily visualizes left atrial morphology and may be used as an alternative. In 6 of 21 patients with mitral valve stenosis, a left atrial appendage thrombus was diagnosed by transesophageal two-dimensional echocardiography when transthoracic echocardiography had failed. The transesophageal echocardiographic findings were confirmed at surgery for mitral valve replacement in all cases.

Transesophageal two-dimensional echocardiography: comparison of ultrasonic and anatomic sections

Conventional 2-dimensional echocardiography has become a well-established tool for evaluating cardiovascular diseases. Recent introduction of 2-dimensional transesophageal echocardiography has widened the ultrasonic examination possibilities of the heart and great arteries. The 6 standard transesophageal transducer positions that have proved representative and of diagnostic value are described. To facilitate structure identification and interpretation of anatomic relations, transesophageal recordings were compared with corresponding anatomic sections.