Ann Thorac Surg 2006;82:1510-1512
© 2006 The Society of Thoracic Surgeons
Case Reports
How Fast Does an Atrial Myxoma Grow?
Eva Karlof, MD,
Sacha P. Salzberg, MD,
Anelechi C. Anyanwu, MD,
Barry Steinbock, CCP,
Farzan Filsoufi, MD*
Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, New York
Accepted for publication November 7, 2005.
* Address correspondence to Dr Filsoufi, Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Ave, Box 1028, New York, NY 10029 (Email: farzan.filsoufi{at}mountsinai.org).
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Abstract
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We describe the case of a 58-year-old man who underwent coronary artery bypass grafting with an unremarkable transesophageal echocardiogram. Three years later he underwent a routine transthoracic echocardiogram that was normal. Eleven months later he presented with dyspnea and right-sided heart failure. Transthoracic echocardiogram showed a large mass located in the right atrium in which the base was inserted by the junction of the inferior vena cava and coronary sinus. Pathology showed a myxoma that measured 15 x 3 cm implying a growth rate of 1.36 x 0.3 cm/month.
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Introduction
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Cardiac myxomas are rare benign tumors of the heart. The growth rate of these tumors remains unknown [1, 2]. We present the case of a rapidly growing right atrial myxoma after prior cardiac surgery.
A 58-year-old man with a medical history of coronary artery disease underwent coronary artery bypass grafting in 2000. Intraoperative transesophageal echocardiogram showed no intracardiac lesions. Routine transthoracic echocardiogram in 2003 was unremarkable (Fig 1A). Eleven months later he presented with dyspnea and peripheral edema. A transthoracic echocardiogram showed a large mass in the right atrium extending through the tricuspid valve into the right ventricle, causing temporary obstruction of the tricuspid orifice (Fig 1B). The right ventricle was mildly dilated with normal function.
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Fig 1. (A) (Left): Transthoracic echocardiogram (parasternal view), showing no myxoma in the right atrium or ventricle (June 2003). (B) (Right): Transthoracic echocardiogram (four-chamber view) showing a large mass (May 2004). (Ao = aorta; LA = left atrium; Myx = myxoma; RA = right atrium; RV = right ventricle.)
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Reoperative surgery was performed through a median sternotomy with cardiopulmonary bypass instituted between the ascending aorta, superior vena cava, and right femoral vein. Cardioplegic arrest was instituted. A transverse right atriotomy was performed. A pedunculated mass was found with its base attached between the Eustachian valve and the inferior edge of the coronary sinus. This atrial mass was extending through the tricuspid valve into the right ventricle (Fig 2A). It was completely excised with its attachment and the resultant atrial defect was primarily repaired. The mass measured 15 x 3 cm (Fig 2B). The tricuspid valve was normal and competent. He was easily weaned from cardiopulmonary bypass and discharged home 1 week after surgery without complication. Histology demonstrated myxoid stroma containing single and small groups of lepidic cells and a few small vessels, consistent with myxoma (Fig 2C). The patient remains asymptomatic 1 year after surgery with no recurrent myxoma on transthoracic echocardiogram.
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Fig 2. (Left) Right mass immediately visualized after atriotomy. (Middle) Excised mass measuring approximately 15 cm in length. (Right) Low power photomicrograph of atrial myxoma shows myxoid stroma containing single and small groups of lepidic cells and a few small vessels (Hematoxylin and eosin; x100).
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Comment
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Cardiac myxomas are most often encountered in the left atrium (80% to 90%) with approximately 10% to 20% observed in the right atrium [1]. Myxomas are most frequently attached to the interatrial septum [3]. They may trigger dramatic complications such as heart failure, syncope, or sudden death because of obstruction of the atrioventricular valves [1]. We have described a large right atrial myxoma with a rapid growth rate and a rare insertion site.
Because myxomas are usually excised after diagnosis, their growth rate is generally unknown [1, 2]. However, on occasion, if prior echocardiography is available for comparison, or where surgery is declined or contraindicated, information may be obtained regarding the growth rate [3, 4].
Some previous reports have attempted to estimate the growth rate of myxoma (Table 1). Two reports described patients who underwent previous coronary artery bypass grafting and presented with left atrial myxoma after 8 and 18 months [4, 5]. In these series, the growth rate was estimated at 0.44 cm/month and 0.33 cm/month, respectively, assuming that the tumor started to develop immediately after initial surgery. Two publications reported serial echocardiograms in which the tumor was not excised due to medical contraindication or patient refusal [3, 6]; growth rate was estimated at 0.13 cm/month and 0.018 cm2/month, respectively. Two other reports presented patients with serial echocardiograms, but with quiescent growth rate [7, 8]. In our case, no mass was apparent on the transthoracic echocardiogram 11 months prior to surgery implying a minimum growth rate of 1.36 x 0.27 cm/month. However, without serial echocardiograms, we are unable to accurately delineate this growth pattern. In calculating these growth rates it is assumed that tumors grow in a linear fashion; in reality growth may be exponential such that the estimated growth rate would vary depending on when the diagnosis is made. The major differential diagnosis of myxoma is thrombus, which often has rapid growth. As we have observed a rapid growth in a myxoma, we would caution against using rapidity of the growth rate as a diagnostic criterion to differentiate between thrombus and myxoma. The potential of rapid growth rate should be considered if there is a plan to delay surgery or to manage the myxoma expectantly.
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References
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- Reynen K. Cardiac myxomas N Engl J Med 1995;333:1610-1617.[Free Full Text]
- Malekzadeh S, Roberts WC. Growth rate of left atrial myxoma Am J Cardiol 1989;64:1075-1076.[Medline]
- Iga K, Izumi C, Konishi T. Rapid growth of a left atrial myxomaSerial two-dimensional echocardiographic observation over eighteen months. Int J Cardiol 1997;61:85-87.[Medline]
- Roudaut R, Gosse P, Dallocchio M. Rapid growth of a left atrial myxoma shown by echocardiography Br Heart J 1987;58:413-416.[Abstract/Free Full Text]
- Marinissen KI, Essed C, de Groot C, Schelling A, Hagemeijer F. Growth rate of left atrial myxomaDevelopment of a symptomatic left atrial myxoma less than two years after coronary artery bypass grafting. Chest 1987;92:941-942.[Abstract/Free Full Text]
- Ullah W, McGovern R. Natural history of an atrial myxoma Age Ageing 2005;34:186-188.[Abstract/Free Full Text]
- Lane GE, Kapples EJ, Thompson RC, Grinton SF, Finck SJ. Quiescent left atrial myxoma Am Heart J 1994;127:1629-1631.[Medline]
- Kay JF, Chow WH. Long-term survival of quiescent left atrial myxoma in an elderly patient Am J Geriatr Cardiol 2002;11:165-168.[Medline]
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Abstract
Introduction
