Myxoma attached solely to the tricuspid valve

CASEREPORTS ma. The immediate postoperative course was uneventful. There are published reports of 2 cardiac myxomas arising from the David J. Cole, MD, William G. Hendren, MD, James D. Sink, MD, mitral valve, and 1 of a cardiac myxand Paul H. D’Amato, MD oma originating from the pulmonary valve. A review of published reports alvular cardiac myxoma is rare. trocardiogram. Two-dimensional revealed 10 patients with tricuspid We report a patient with a large echocardiographyshoweda large (4 valvular myxoma.l-lo myxoma arising from the tricuspid X 4 cm) echolucentoval massin the Of these 10 patients, 4 had tumor valve. right atrium arisingfrom the anteri- attachment on the atria1 side of the A 74-year-old man presented or portion of the septal leaflet of the valve2J,7Joand 6 on the ventricular with acute right-sided heart failure. tricuspid valve. The massprolapsed side.1*4-638,9 Although these tumors There was no previous history of through the valve in late diastole and are rare, it appears that right-sided cardiac symptoms, syncopeor fever. completely entered the right ventri- valvular involvement is more comOn physical examination, bilateral cle until early systole (Figure 1). M- mon than that on the left side, Rerales, severelower extremity edema mode echocardiography revealed a view of the reports of tricuspid valvuand a palpable liver were present. discrete mass behind the tricuspid lar myxomas revealed no distinct Cardiac examination showedsignif- valve, with a lag phase seen during clinical featuresthat would allow the icant jugular venous distension, a diastole consistentwith the a-dime+ specific diagnosis of involvement of displaced impulse and a loud S3gal- sional echocardiography findings. the tricuspid valve. However, 3 of the lop. Chest x-ray demonstratedpul- No other abnormalities were seen. 5 patients with tumors originating on the atria1 side of the valve, including monary edema and cardiomegaly. The operation was undertaken Atrialfibrillation and a right bundle through the right atrium on total our own patient, presented with branch block werenoted on the elec- cardiopulmonary bypass. A solid acute right-sided heart failure.*JO massmeasuring 4 X 6 cm wasfound Intraventricular tumors basedon the From the Divisions of Cardiothoracic Surgery attached by a short stalk to the sep- tricuspid valve also presented most and Cardiology, Decatur Veterans Adminis- tal leajlet of the tricuspid valve. The commonly with right-sided heart tration Medical Center and Emory University masswasremovedwith excision of a failure, followed by syncopeand feSchool of Medicine. Atlanta. Georgia 30322. Manuscript receiveb May i5, 1989; revised small ellipse of valve leaflet at the ver of unknown origin. Only 3 of the previously reported patients with trimanuscript received and accepted May 30, base.The leajlet was reapproximated. Pathology showed benign myo- cuspid valve myxoma underwent 1989. echocardiographic procedures,*v3J0 but the findings were similar to ours. In our patient, we localized a mass arising from the tricuspid valve leaflet with both 2-dimensional and Mmodeechocardiography,and demonstrated complete prolapse into the right ventricle during systole. In our patient and in the 3 previouspatients in whom echocardiography showed valvular origin of these tumors, prolapse into the ventricle was clearly demonstrated. Thus, cardiographic findings of right atria1masswith prolapse during cardiac contraction should suggestvalvular origin of the tumor.

Myxoma Attached Solely to the Tricuspid Valve

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1. Dang CR, Hurley EJ. Contralateralrecurrent myxomaof the heart. Ann Thorac Surg 1976;21:5962. 2. Worthington M, GleasonT, PandianNG, Daly B.

nt?uRE 1. Two-8m (&ql&8l bdmnber dew) shows &ilt-ddededmohmtm8ss~ illtOthOligiltVS4lbih(8fWW).TlW operation-myxemawithorighontharepbl~oftheMcurpid vdve. 546

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Tricuspid valve myxoma infected with dysgonic fermenter. South Med J 1984;77:241-242. 3. Courdier G, Kicny R, EisenmannB, Grison D, Hesscl F, Ameur C, ChemounyJP, Legutke D. Laval G. Echographicd’un myxome de la valve tricuspid opere. Arch Mal Coetu 1981,6:747-759. 4. DeMaria AN, Vismara LA, Miller RR, Neumann A, Mason DT. Unusual echographicmanifes-

tations of right and left heart myxomas.Am J Med

pects of right ventricular myxoma. Br J Radial

Heart J 19769:240-243.

1974$9:713-720.

1964:37:468-471.

5. Suri RK, Pattankar VL, Singh H, Aikat BK, Gujral JS. Myxoma of the tricuspid valve. Aust N Z

7. Jaleski TC. Myxoma of the heart valves-report of a case.Am Pathol 1934;10:399-403. 8. Snyder SN. Smith DC, Lau FYK, Turner AF. Diagnostic featuresof right ventricular myxoma.Am

9. Hubbard TF, Neil RN. Myxoma of the right ventricle. Am Heart J 1971;81:548-553. 10. Richardson JV, Brandt 9, Doty DB, Ehrenhaft JL. Surgical treatment of atrial myxoma. Ann

J Surg 1978;43:429-432.

6. Crummy AB, Hipona FA. The radiographic as-

Thorac Surg 1978:28:354-358.

3..5-MHz sector scanner with a fast Fourier transformation spectral velocity output.’ Color flow mapping images were obtained in real time. A turbulent forward flow was recorded Jean-Claude Fouron, MD, David J. Sahn, MD, Robert Bender, MD, in the main pulmonary artery and its branches during systole. In diastole, Richard Block, MD, Howard Schneider, MD, Patricia Fromberger, MD, a retrogradejlow was noted not only Sandy Hagen-Ansert, RDMS, and Pat 0. Daily, MD in the pulmonary arteries but also in the outflow tract of the right ventrietralogy of Fallot with absent identify this strucure as dilated pulmonary valve is a form of cy- branches of the pulmonary artery cle (a pulmonary stenosis insufficiency pattern); peak velocities were anotic heart diseasethat can cause connecting with the main pulmonary severerespiratory distresssoon after artery, which was also aneurysmal higher for the backward flow combirth.le3 Proper management of the (Figure I). pared with the forward flow. It was never possible to visualize A low velocity, turbulent rightdiseaseis closely linked to its early recognition. Ideally, prenatal diagno- any connecting vessel between the to-left shunt was recorded through sis4-6should allow planning of deliv- pulmonary trunk and the descending the interventricular defect both in ery in medical centers equipped to aorta as a distal ‘pulmonary” arch systole and in diastole (Figure 2A). provide prompt medical and surgical suggesting absence of a patent duc- The aneurysms in the pulmonary care to these potentially critically ill tus arteriosus. A few dense echoes arteries appeared filled with turbunewborn infants. Recently, 2 fetuses were noted at the level of thepulmolent flow on the flow map echocarwith this syndromewere encountered nary valve compatible with the fidiogram (Figure 2B). in the Consultative Fetal Echocar- brous ridges, but no valve tissue was The family was counselled and diographic Clinic of the University of observed. plans were made to have delivery atCalifornia Medical Center at San In the 4-chamber view the right tended by a neonatologist, a pediatDiego. ventricle was larger than the left, ric cardiologist and the high risk obCASE 1:A 22-year-old gravida 1, which was of normal size. A subaorstetrics team at Kaiser Permanente. para 0 woman was referred to this tic ventricular septal defect with aor- Delivery occurred 5 weeks later. At clinic at an estimated gestational age tic overriding also was visible in the birth, the 2.8-kg female infant cried same view (Figure 1B). twice and then, because she had seof 32 weeks because of a mild polyDoppler flow analysis was per- vere chest retractions and the obhydramnios associated with a dilatation of one of the cardiac ventricu- formed with a Toshiba SSH6SA, served breath sounds suggested airlar cavities and a suggestion of a ventricular septal defect noted during routine obstetrical screening. Cardiac anatomy was first studied with an Acuson system with a 5MHz linear array transducer. At the start of the echocardiographic scanning, large echo-free spaces were visible at the base of the heart, behind the left atrium. By looking at sequential planes, it was possible to

Prenatal Diagnosis and Circulatory Characteristics in Tetralogy of Fallot with Absent Pulmonary Valve

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From the Department of Pediatric Cardiology, Hospital St-Justine, Montreal, Quebec, Canada, the Department of Pediatrics and Obstetrics, Kaiser Permanente Medical Center, San Diego, and the Department of Pediatrics and Surgery, University of California Medical Center, TOOSA,La Jolla, California 92093. Manuscript received December 2, 1988; revised manuscript received May 18, 1989,and acceptedMay 19.

nGUREi.A,rholt-urisvkwtromthefaalechocanColg~lrhowsdropwtof wmbkdarouHlowtract,omnatm8lsizepdmomyanuhs anddUatktnofthadktalptfhmmy aytesy aroa. 4 long-axis fatal view shows overrklingofthoaortaanda~ventricular~taldofoet. tlW-Wdleft

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