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Giant Left Ventricular Myxoma With Obstruction of the Left Ventricular Outflow Tract
Giant Left Ventricular Myxoma With Obstruction of the Left Ventricular Outflow Tract Jian Liu, MD, Hui-Ming Guo, MD, Bin Xie, MD, Hai-Jiang Guo, MD, Ji-Mei Chen, MD, and Jian Zhuang, MD Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
A rare case of giant left ventricular (LV) myxoma with obstruction of the left ventricular outflow tract (LVOT) was found incidentally on echocardiography in an asymptomatic 21-year-old woman. The tumor was successfully resected through transatrial septal access. (Ann Thorac Surg 2016;101:e63–4) Ó 2016 by The Society of Thoracic Surgeons
N
early 75% of primary cardiac tumors are benign, and most are myxomas. About 75% of cardiac myxomas originate from the left atrium and are attached to the atrial septum [1]. LV myxoma is extremely rare, accounting for 2.5% to 4% of all cardiac myxoma cases [2]. We present a case in which a giant myxoma in the left ventricle was successfully excised through the right atrium and atrial septum. A 21-year-old female patient without any symptoms underwent a routine medical examination about 1 week before admission to our hospital, and a giant myxoma was detected in the left ventricle by transthoracic Accepted for publication Sept 15, 2015. Address correspondence to Dr Guo, Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongShanEr Rd, Guangzhou 510080, China; email: [email protected].
echocardiography. Physical examination showed a grade II/IV systolic murmur in the second right intercostal space and the third and fourth left intercostal spaces. Examination with magnetic resonance imaging (MRI) and transesophageal echocardiography (TEE) demonstrated a large mass (about 74 cm in dimension) in the LV cavity attached to the apical portion of the interventricular septum and extending into the LV outflow tract (LVOT) with a systolic prolapse through the aortic valve (Fig 1). LV function was normal, and the other cardiac valves and cavities were free of lesions. Because the patient was at an increased risk of sudden death and systemic embolization from the systolic prolapse of the mass through the aortic valve with severe LVOT obstruction, as well as the characteristics of the myxoma and the high pressure within the left ventricle during systole [3], an urgent resection of the intracardiac mass was required. The patient underwent median sternotomy under general anesthesia, and standard cardiopulmonary bypass was established. After atrial septostomy, we visualized the gelatinous fragile mass on the interventricular septum and then extracted the myxoma through the mitral valve. Postoperative TEE revealed a mild mitral regurgitation with no residual mass, and histopathologic examination confirmed the diagnosis of myxoma (Fig 2).
Comment The most common symptoms of LV myxoma include syncope, angina, and embolism. Occasionally, patients are asymptomatic and are diagnosed unexpectedly. Diagnosis is primarily by TEE or MRI. Because patients are at high risk of sudden death and systemic embolization, tumor resection should be performed as early as possible. The mass is usually removed by a transaortic
Fig 1. Examination by (A) magnetic resonance imaging (MRI) and (B) transesophageal echocardiography (TEE) demonstrated large mass in left ventricle, and tumor protruded through aortic valve in systole with severe obstruction. The arrow in B shows opened aortic valve.
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.09.043
e64
CASE REPORT LIU ET AL LEFT VENTRICULAR MYXOMA
Ann Thorac Surg 2016;101:e63–4
approach to avoid a left ventriculotomy and its potential complications. However, if necessary, exploration through the right atrium and atrial septum can also be performed safely.
References 1. Reynen K. Cardiac myxomas. N Engl J Med 1995;333:1610–7. 2. Hassan M, Smith JM. Robotic assisted excision of a left ventricular myxoma. Interact Cardiovasc Thorac Surg 2012;14: 113–4. 3. Keeling IM, Oberwalder P, Anelli-Monti M, et al. Cardiac myxomas: 24 years of experience in 49 patients. Eur J Cardiothorac Surg 2002;22:971–7.
Fig 2. Histopathologic examination confirms the diagnosis of cardiac myxoma. (Hematoxylin and eosin, 100.)
A rare case of giant left ventricular (LV) myxoma with obstruction of the left ventricular outflow tract (LVOT) was found incidentally on echocardiography in an asymptomatic 21-year-old woman. The tumor was successfully resected through transatrial septal access. (Ann Thorac Surg 2016;101:e63–4) Ó 2016 by The Society of Thoracic Surgeons
N
early 75% of primary cardiac tumors are benign, and most are myxomas. About 75% of cardiac myxomas originate from the left atrium and are attached to the atrial septum [1]. LV myxoma is extremely rare, accounting for 2.5% to 4% of all cardiac myxoma cases [2]. We present a case in which a giant myxoma in the left ventricle was successfully excised through the right atrium and atrial septum. A 21-year-old female patient without any symptoms underwent a routine medical examination about 1 week before admission to our hospital, and a giant myxoma was detected in the left ventricle by transthoracic Accepted for publication Sept 15, 2015. Address correspondence to Dr Guo, Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital and Guangdong Academy of Medical Sciences, 106 ZhongShanEr Rd, Guangzhou 510080, China; email: [email protected].
echocardiography. Physical examination showed a grade II/IV systolic murmur in the second right intercostal space and the third and fourth left intercostal spaces. Examination with magnetic resonance imaging (MRI) and transesophageal echocardiography (TEE) demonstrated a large mass (about 74 cm in dimension) in the LV cavity attached to the apical portion of the interventricular septum and extending into the LV outflow tract (LVOT) with a systolic prolapse through the aortic valve (Fig 1). LV function was normal, and the other cardiac valves and cavities were free of lesions. Because the patient was at an increased risk of sudden death and systemic embolization from the systolic prolapse of the mass through the aortic valve with severe LVOT obstruction, as well as the characteristics of the myxoma and the high pressure within the left ventricle during systole [3], an urgent resection of the intracardiac mass was required. The patient underwent median sternotomy under general anesthesia, and standard cardiopulmonary bypass was established. After atrial septostomy, we visualized the gelatinous fragile mass on the interventricular septum and then extracted the myxoma through the mitral valve. Postoperative TEE revealed a mild mitral regurgitation with no residual mass, and histopathologic examination confirmed the diagnosis of myxoma (Fig 2).
Comment The most common symptoms of LV myxoma include syncope, angina, and embolism. Occasionally, patients are asymptomatic and are diagnosed unexpectedly. Diagnosis is primarily by TEE or MRI. Because patients are at high risk of sudden death and systemic embolization, tumor resection should be performed as early as possible. The mass is usually removed by a transaortic
Fig 1. Examination by (A) magnetic resonance imaging (MRI) and (B) transesophageal echocardiography (TEE) demonstrated large mass in left ventricle, and tumor protruded through aortic valve in systole with severe obstruction. The arrow in B shows opened aortic valve.
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.09.043
e64
CASE REPORT LIU ET AL LEFT VENTRICULAR MYXOMA
Ann Thorac Surg 2016;101:e63–4
approach to avoid a left ventriculotomy and its potential complications. However, if necessary, exploration through the right atrium and atrial septum can also be performed safely.
References 1. Reynen K. Cardiac myxomas. N Engl J Med 1995;333:1610–7. 2. Hassan M, Smith JM. Robotic assisted excision of a left ventricular myxoma. Interact Cardiovasc Thorac Surg 2012;14: 113–4. 3. Keeling IM, Oberwalder P, Anelli-Monti M, et al. Cardiac myxomas: 24 years of experience in 49 patients. Eur J Cardiothorac Surg 2002;22:971–7.
Fig 2. Histopathologic examination confirms the diagnosis of cardiac myxoma. (Hematoxylin and eosin, 100.)