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Correspondence

Multimodal Imaging Characterization of Intracardiac Thrombus and Myxoma

Department of Cardiothoracic Surgery and Cardiac Magnetic Resonance Imaging Department, Mount Sinai School of Medicine, 1190 Fifth Ave, New York, NY 10029-1028

(Email: farzan.filsoufi{at}mountsinai.org).

To the Editor:

We read with interest the article from Sheikh and colleagues [1] reporting on the formation of an atrial mass 3 years after primary repair of an atrial septal defect. Transthoracic and transesophageal echocardiography, as well as magnetic resonance imaging (MRI), were apparently highly consistent with an atrial myxoma. However, histologic examination after reoperation and removal of the mass revealed the mass to be an atrial thrombus.

We agree with the authors that preoperatively differentiating between intracardiac myxoma and thrombus may be difficult. Clinical symptoms, if present, may be similar, particularly with respect to intracardiac obstruction and peripheral embolization. In addition, atrial thrombi frequently mimic echocardiographic features of atrial myxoma, making an accurate diagnosis difficult [2]. We would caution against using tumor growth rate as a diagnostic criterion to differentiate between thrombus and myxoma, because (as we have previously reported) the growth rate of cardiac myxomas varies among individuals [3].

In contrast to the authors' report, we have found that cardiac MRI as part of a multimodal diagnostic approach provides important additional information, which reliably allows a distinction to be made preoperatively between these two entities [4, 5]. Hypointensity on T1-weighted images and hyperintensity on T2-weighted images relative to the myocardium, suggestive of tissue with high extracelluar water content, are features commonly observed in myxoma [5]. In addition, myxomas typically show a heterogeneous appearance in MRI, both before and after contrast administration, due to areas of necrosis or hemorrhage. Furthermore, atrial thrombi typically have a brighter appearance than tumor or myocardium in inversion-recovery imaging with short inversion times and a darker appearance with long inversion times. In our experience, the cine image shown by Sheikh and colleagues [1] is insufficient for accurate differential diagnosis.

Using this multimodal approach in a series of cardiac myxoma, we have described how cardiac MRI demonstrates specific characteristics of myxomatous tissue and facilitates preoperative diagnosis [5]. We have also reported a very similar case of an atrial mass after an atrial septal defect repair [4]. Transthoracic echocardiography demonstrated a large, mobile mass in the right atrium. The mass was further characterized with contrast transesophageal echocardiography and delayed enhancement MRI, which together suggested a thrombus, attached to the Eustachian valve. Postoperatively, the diagnosis was confirmed histologically.

Although the determination of the exact cause of a cardiac mass may be challenging, we believe that cardiac MRI provides valuable information regarding tissue characteristics and allows the preoperative differentiation between thrombus and myxoma in most patients.

	References

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1. Sheikh AY, Schrepfer S, Stein W, et al. Right atrial mass after primary repair of an atrial septal defect: thrombus masquerading as a myxoma Ann Thorac Surg 2007;84:1742-1744.[Abstract/Free Full Text]
2. Perez de Isla L, de Castro R, Zamorano JL, et al. Diagnosis and treatment of cardiac myxomas by transesophageal echocardiography Am J Cardiol 2002;90:1419-1421.[Medline]
3. Karlof E, Salzberg SP, Anyanwu AC, Steinbock B, Filsoufi F. How fast does an atrial myxoma grow? Ann Thorac Surg 2006;82:1510-1512.[Abstract/Free Full Text]
4. Nemirovsky D, Salzberg SP, Einstein AJ, et al. Multimodal characterization of a large right atrial mass after surgical repair of an atrial septal defect Mt Sinai J Med 2006;73:1117-1119.[Medline]
5. Rahmanian PB, Castillo JG, Sanz J, Adams DH, Filsoufi F. Cardiac myxoma: preoperative diagnosis using a multimodal imaging approach and surgical outcome in a large contemporary series Interact Cardiovasc Thorac Surg 2007;6:479-483.[Abstract/Free Full Text]

This article has been cited by other articles:

				A. Y. Sheikh and M. P. Pelletier Reply Ann. Thorac. Surg., June 1, 2008; 85(6): 2162 - 2163. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Farzan Filsoufi Javier G. Castillo Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Filsoufi, F. Articles by Sanz, J. Search for Related Content PubMed PubMed Citation Articles by Filsoufi, F. Articles by Sanz, J. Related Collections Congenital - acyanotic Related Article