- Email: [email protected]
Multimodal Imaging Characterization of Intracardiac Thrombus and Myxoma
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CORRESPONDENCE
detecting less than critical (⬍75%) anastomotic narrowing [4]. Measurements on the posterolateral and posterior aspects on the heart were especially unreliable, especially in the presence of epicardial fat. For similar reasons, other institutions [5] after initial enthusiasm of coronary thermal angiography also discontinued its application. We respectfully disagree with the authors that coronary thermal angiography is either new or that it has an acceptable sensitivity to detect important morphologic changes short of more than critical narrowing. Francis Robicsek, MD, PhD Department of Cardiovascular and Thoracic Surgery Carolinas Medical Center 1001 Blythe Blvd, No. 300 Charlotte, NC 28203 e-mail: [email protected]
References 1. Iwahashi H, Tashiro T, Morishige N, et al. New method of thermal coronary angiography for intraoperative patency control in off-pump and on-pump coronary artery bypass grafting. Ann Thorac Surg 2007;84:1504 –7. 2. Robicsek F, Masters TN, Niesluchowski W, Born GVR. The effects of adenosine upon the coronary circulation studied by thermography. Vasc Surg 1984;18:135– 40. 3. Robicsek F. A simple test to determine the efficiency of mammary artery grafts during operation. Ann Thorac Surg 1985;39:388 –9. 4. Robicsek F, Masters TN, Svenson RH, et al. The application of thermography in the study of coronary blood flow. Surgery 1978;84:858 – 64. 5. Mohr FW, Matloff J, Grundfest W, et al. Thermal coronary angiography: a method for assessing graft patency and coronary anatomy in coronary bypass surgery. Ann Thorac Surg 1989;47:441–9.
Multimodal Imaging Characterization of Intracardiac Thrombus and Myxoma To the Editor:
MISCELLANEOUS
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, © 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2008;85:2161–5
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. Farzan Filsoufi, MD Joanna Chikwe, FRCS-CTh Javier G. Castillo, MD Javier Sanz, MD Department of Cardiothoracic Surgery and Cardiac Magnetic Resonance Imaging Department Mount Sinai School of Medicine 1190 Fifth Ave New York, NY 10029-1028 e-mail: [email protected]
References 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– 4. 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 –21. 3. Karlof E, Salzberg SP, Anyanwu AC, Steinbock B, Filsoufi F. How fast does an atrial myxoma grow? Ann Thorac Surg 2006;82:1510 –2. 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;73:1117–9. 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 – 83.
Reply To the Editor: We appreciate the comments put forth by Dr Filsoufi and colleagues [1] regarding our article [2] and agree that magnetic resonance imaging is a useful adjunct to help determine the nature of atrial masses preoperatively. 0003-4975/08/$34.00
CORRESPONDENCE
detecting less than critical (⬍75%) anastomotic narrowing [4]. Measurements on the posterolateral and posterior aspects on the heart were especially unreliable, especially in the presence of epicardial fat. For similar reasons, other institutions [5] after initial enthusiasm of coronary thermal angiography also discontinued its application. We respectfully disagree with the authors that coronary thermal angiography is either new or that it has an acceptable sensitivity to detect important morphologic changes short of more than critical narrowing. Francis Robicsek, MD, PhD Department of Cardiovascular and Thoracic Surgery Carolinas Medical Center 1001 Blythe Blvd, No. 300 Charlotte, NC 28203 e-mail: [email protected]
References 1. Iwahashi H, Tashiro T, Morishige N, et al. New method of thermal coronary angiography for intraoperative patency control in off-pump and on-pump coronary artery bypass grafting. Ann Thorac Surg 2007;84:1504 –7. 2. Robicsek F, Masters TN, Niesluchowski W, Born GVR. The effects of adenosine upon the coronary circulation studied by thermography. Vasc Surg 1984;18:135– 40. 3. Robicsek F. A simple test to determine the efficiency of mammary artery grafts during operation. Ann Thorac Surg 1985;39:388 –9. 4. Robicsek F, Masters TN, Svenson RH, et al. The application of thermography in the study of coronary blood flow. Surgery 1978;84:858 – 64. 5. Mohr FW, Matloff J, Grundfest W, et al. Thermal coronary angiography: a method for assessing graft patency and coronary anatomy in coronary bypass surgery. Ann Thorac Surg 1989;47:441–9.
Multimodal Imaging Characterization of Intracardiac Thrombus and Myxoma To the Editor:
MISCELLANEOUS
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, © 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2008;85:2161–5
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. Farzan Filsoufi, MD Joanna Chikwe, FRCS-CTh Javier G. Castillo, MD Javier Sanz, MD Department of Cardiothoracic Surgery and Cardiac Magnetic Resonance Imaging Department Mount Sinai School of Medicine 1190 Fifth Ave New York, NY 10029-1028 e-mail: [email protected]
References 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– 4. 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 –21. 3. Karlof E, Salzberg SP, Anyanwu AC, Steinbock B, Filsoufi F. How fast does an atrial myxoma grow? Ann Thorac Surg 2006;82:1510 –2. 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;73:1117–9. 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 – 83.
Reply To the Editor: We appreciate the comments put forth by Dr Filsoufi and colleagues [1] regarding our article [2] and agree that magnetic resonance imaging is a useful adjunct to help determine the nature of atrial masses preoperatively. 0003-4975/08/$34.00