Ann Thorac Surg 1998;65:1768-1769
© 1998 The Society of Thoracic Surgeons
Case Reports
Biatrial Myxoma: A Rare Cardiac Tumor
John L. Peachell, MDa,
John C. Mullen, MDa,
Michael J. Bentley, BSca,
Dylan A. Taylor, MDb
a Division of Cardiothoracic Surgery, University of Alberta, Edmonton, Alberta, Canada
b Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
Accepted for publication December 16, 1997.
Address reprint requests to Dr Mullen, Departments of Surgery and Pediatrics, University of Alberta Hospital, 2D2.18 WC Mackenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta, Canada T6G 2B7
e-mail: (jmullen{at}gpu.srv.ualberta.ca)
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Abstract
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A previously healthy 48-year-old man presented to the hospital with a transient ischemic attack. Echocardiography revealed a large left atrial tumor with a second tumor in the right atrium. Surgical excision revealed a large left atrial myxoma with extension through the interatrial septum into the right atrium.
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Introduction
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Cardiac myxomas represent approximately 50% of all benign cardiac tumors, with left atrial myxomas accounting for more than 70% [1]. Biatrial myxomas are extremely rare [2]. We describe the successful management of a middle-aged man with a huge biatrial myxoma.
A healthy 48-year-old man presented with a sudden transient ischemic attack manifested by loss of vision in his right eye, which resolved spontaneously after 2 hours. He had a single episode of seizure activity 12 years earlier, for which he had been given phenytoin. He also had a 30 pack/year history of smoking. The results of a neurologic examination were normal, but a cardiovascular examination revealed a middiastolic murmur with diastolic "plop" (caused by the left atrial tumor dropping into the mitral valve during diastole). A computed tomographic scan of the head and carotid Doppler studies were normal. Echocardiography revealed a large left atrial tumor and smaller right atrial tumor (Fig 1). A magnetic resonance scan (Fig 2) was performed to exclude malignancy. Coronary angiography revealed normal coronary arteries. He was advanced for an urgent operation.
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Fig 1. Transesophageal echocardiogram (basal horizontal view) demonstrating large left and smaller right atrial components of biatrial myxoma (M). (Ao = aorta; LA = left atrium; RA = right atrium; S = septum.)
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Fig 2. Magnetic resonance scan showing biatrial myxoma (M) and lack of extracardiac extension. (Ao = aorta; LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle; S = septum.)
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At operation, he was placed on cardiopulmonary bypass with bicaval cannulas and the heart was arrested with cold blood cardioplegia. The right atrium was opened widely, and after visualization of the right atrial component, the left atrium was opened through the interatrial septum. The tumor (Fig 3) had invaded through the interatrial septum and one component had invaded the posterior left atrial wall. The tumor was completely excised with a surrounding 6-mm margin of interatrial septum and a portion of the posterior wall of the left atrium. The resultant atrial septal defect (3.5 cm in diameter) was closed with an autologous pericardial patch.
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Fig 3. Intraoperative photograph of the huge biatrial myxoma. (LAM = left atrial myxoma; RAM = right atrial myxoma; S = septum.)
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The operative specimen weighed 46 g and measured 5.5 x 5 x 3 cm (Fig 4). The left atrial component was significantly larger than the right and both tumor stalks grew from opposite sides of the same area of the interatrial septum. Histologic examination revealed a myxoma with no signs of malignancy. His postoperative course was uncomplicated and he continues to do well at 7-month follow-up with no evidence of recurrence.
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Comment
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Yipintsoi and associates [3] described the first successful removal of a biatrial myxoma in 1967. Since then, there have been 19 additional reports of this tumor in the literature. Typically, myxomas are found in the left atrium (75%) or right atrium (20%), with occasional tumors found in the ventricles (5%). Multiple tumors are found in approximately 5% of cases. Biatrial tumors are found in less than 2.5% of all myxoma cases [4]. In the last 6 years, we have resected 16 myxomas: 12 left atrial, 3 right, and 1 biatrial. Echocardiography continues to be the diagnostic procedure of choice in delineating the location and extent of atrial myxomas [5]. Because of the unusual appearance of this multicentric tumor, magnetic resonance imaging was employed to rule out intracardiac or extracardiac extension as is often seen with malignant cardiac tumors. The patient was advanced for urgent operation because of the risk of further embolic episodes. Wide exposure was obtained by a transseptal biatrial incision.
Biatrial myxoma is an extremely rare occurrence and may present a diagnostic challenge. Once a diagnosis is established, these tumors should be removed to prevent further cardiac or neurologic sequelae. With complete resection the recurrence rate should be less than 5% [6], and patients should be followed up with serial echocardiography.
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Acknowledgments
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We thank Dr Ravi Bhargava (Department of Diagnostic Imaging, WC Mackenzie Health Sciences Centre, University of Alberta) for his assistance in interpretation of the magnetic resonance imaging scan.
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References
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- Sabiston D.C., Hattler B.G. Tumors of the heart. In: Sabiston D.C., Spencer F.C., eds. Gibbons surgery of the chest, 4th ed. Philadelphia: Saunders, 1983:1585.
- Imperio J., Summers D., Krasnow N., Piccone V.A., Jr The distribution patterns of biatrial myxomas. Ann Thorac Surg 1980;29:469-473.[Abstract/Free Full Text]
- Yipintsoi T., Donavanik L., Bhamarapravati N., Jumbala B., Prachaubmoh K. Bilateral atrial myxoma with successful removal. Report of a case. Dis Chest 1967;52:828-834.
- Bojar R.M. Cardiac tumors. In: Bojar R.M., ed. Adult cardiac surgery. Boston: Blackwell Scientific, 1992:358.
- Pechacek L.W., Gonzalez-Camid F., Hall R.J., et al. The echocardiographic spectrum of atrial myxoma: a ten-year experience. Tex Heart Inst J 1986;13:179-195.
- Castells E., Ferran V., Octavio de Toledo M.C., et al. Cardiac myxomas: surgical treatment, long-term results and recurrence. J Cardiovasc Surg 1993;34:49-53 .[Medline]
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Abstract
Introduction
