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"Quality is not an act. It is a habit."


Aristotle


Right atrial mixoma

date : 06.04.2011


G.Kirova
D.Nikolov
T.Jakimov
N.Zlatareva


Imaging Diagnostic Department Tokuda Hospital Sofia 51B Vapzarov blvd 1407 Sofia

kirovag@yahoo.com


Keywords: MDCT, right atrium, mixoma, tricuspidal valve, breast cancer


Clinical history: 56y old woman operated for an Invasive ductal brest cancer. During the routine follow-up she complained for dyspnoea worsening on exertion. On examination, the heart sounds and blood pressure were normal. A 12-lead electrocardiogram and chest x-ray appeared to be normal (fig.1).


Imaging findings:

On a transthoracic echocardiographic study, subcostal 4 chamber view a mobile mass of 6.5 × 4.5 × 4.7 cm in the right atrium was detected. The mass was highly echogenic and appeared protruding through the tricuspid valve into the right ventricle (Fig.2) The interatrial septum was normal in appearance. The presence of a large RA mass was also confirmed by MDCT. On the axial MDCT images a large lobulated tumor mass is present in the right atrium. Slight attachment to the lateral atrial wall is suggested. On dynamic images protrusion through the tricuspidal valve into the right ventricule is present (fig.3, fig.4). The structure of the mass is homogeneous with no enahncement during the early ventricular phase. The mass is slightly lobulated with smooth contours with a tail, freely mooving in the right cardiac cavities (fig.5). There is no sign of PE. Normal sized PA and right atrium were detected. Abnormal diastolic filling of right ventricle. No singns of pulmonary or mediastinal inva


Final diagnosis: Freely mooving right atrial myxoma


Discussion:

Myxomas accounts for one half of all primary cardiac tumors and ususally affect women around their fifty. Most common complaints are atypical, constitutional, but in some cases embolic events are the first presentation. The other mode of presentation is obstruction of blood flow with symptoms of valve stenosis as in our case. Less than 10% are associated with Carney complex – skin pigmentation, endocrine disorders and familial predisposition. Most of the cases are described in the left cardiac cavities with less than 15% arizing from the right side. TTE studies usually yield adequate images for the diagnosis of cardiac tumors. MDCT and MRI of the heart may offer valuable assistance in patients with poor acoustic windows by virtue of confirming tumor attachment site and dimensions, detecting other masses, and defining any obstruction to flow. For a cardiac myxoma a well delinated, smooth, lobulated atrial mass attached to the endocardium is characteristic. The origin near to the fossa ovalis is typical. The tumor is usually ovoid or polypoid, may be pedunculated, allowing it to protrude across the valve in diastole. Typically, myxomas present as nonhomogeneous mass due to the presence of fibrous, necrotic, hemorrhagic and sometimes calcified tissue inside. The tumor enhances which generaly differentiate it from intracavitary thrombus. The treatment of choice for myxomas is surgical removal. Operative mortality ranges from 0% to 3% in multiple series. Recurrence rates are between 1% and 3% for sporadic myxomas, as a result of incomplete resection, versus 12% for familial myxomas.


Differential diagnosis:

1.Atrial thrombus Freely mooving right atrial thrombus is a rare finding. Lack of enhancement is highly suggestive for an intraatrial thrombus and its presence requires emergency operation in order not to produce massive PE 2.Breast cancer metastasis In case of known invasive breast cancer intracardial metastasis is highly suggestive. Imaging presentation is non specific. 3.Angiosarcoma An atrial sarcoma typically involves the right atrium and presents as an infiltrative, lobulated, highly vascularzed mass


Take home messages:

atrial myxomas and thrombi can have similar imaging characteristics contrast enhancement is typical for cardiac tumors attachment to the interatrial setum and freely mooving through the valve is typical for atrial myxoma


Bibliography:

1.M.L. Grebenc, M.L. Rosado-de-Christenson, C.E. Green et al; Atrial Myxomas and Thrombi: Comparison of Imaging Features on CT; Am. J. Roentgenol.2009 192:6 2.JA Carney, H Gordon, PC Carpenter et al; The complex of myxomas, spotty pigmentation and endocrine over activity. Medicine 1985; 64:270-283 3.L.Muzzi, G.Pugliese, I.D’Angeli et al; Giant cardiac myxoma: Real-time characterization by 64-slice computed tomography; J Thorac Cardiovasc Surg 2009;138:493-495© 2009 The American Association for Thoracic Surgery 4.S. Mittle, A.N. Makaryus, L.Boutis et al: Right-Sided Myxomas; J Am Soc Echocardiogr 2005, 16:695 5.S. Lamparter, R. Moosdorf, B. Maisch: Giant Left Atrial Mass in an Asymptomatic Patient; Heart 2004, 90:e24



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