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Myxoma producing right-sided inflow and outflow obstruction
International Journal of Cardiology 79 (2001) 325–326 www.elsevier.com / locate / ijcard
Letter to the Editor
Myxoma producing right-sided inflow and outflow obstruction a, b K.M. Krishnamoorthy *, N.B. Desai a
b
Department of Cardiology, Sri Sathya Sai Institute of Higher Medical Sciences, Puttaparthi 515 134, India Department of Cardiac Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Puttaparthi 515 134, India Received 6 March 2001; accepted 6 March 2001
1. Introduction A huge myxoma occupied the entire right heart producing obstruction to both inflow and outflow on the right side. This uncommon manifestation of a common tumor has not been reported.
2. Case report A 25-year-old man presented with fatigue, fever and weight loss of 3 months duration. He had plethoric face and lips with oedema of face, neck, arms and legs. Veins were dilated and tortuous over the neck, arms and abdominal wall. Liver was enlarged. Anaemia and high sedimentation rate were present. There was a systolic murmur of right ventricular (RV) outflow tract obstruction. Transthoracic echocardiography showed a myxoma occupying the whole of the right atrium (RA) and RV. The tumour was class IV according to Charuzi’s criteria [1]. It had an ovoid shape with a smooth surface and pingpong movement with each cardiac cycle. RA and RV cavity were more than double the size of left atrium (LA) and left ventricle (LV), respectively. In spite of that, the available RA and RV cavity was diminished as the tumor occupied the whole of RA and RV. It encroached upon the orifices of both superior and inferior vena cavae. These were obstructed and *Corresponding author. Present address: SCTIMST, Trivandrum — 695 011, India. Tel.: 191-471-555532; fax: 191-471-446433. E-mail address: [email protected] (K.M. Krishnamoorthy).
dilated. There was pericardial effusion. The tumor also extended to the RV outflow tract producing severe obstruction with a peak Doppler gradient of 80 mmHg. Areas suggesting haemorrhage in the tumor were present. Transoesophageal echocardiography was done to improve definition of the tumor. It showed the slit-like available cavity of RA and RV (Fig. 1). Although LA and LV are only partly visible in the figure, their cavity is much less than that available in RA and RV. Extension of the tumor to the RV outflow tract producing obstruction was seen (Fig. 2). During surgery, the tumour was seen to
Fig. 1. Transoesophageal echocardiographic view. RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle. Pericardial effusion is seen.
0167-5273 / 01 / $ – see front matter 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 01 )00434-X
326
K.M. Krishnamoorthy, N.B. Desai / International Journal of Cardiology 79 (2001) 325 – 326
Fig. 2. Transoesophageal echocardiographic view. LA, left atrium; Ao, aorta; RVOT, right ventricular outflow tract.
occupy the whole of RA and RV. The tricuspid valve was normal but failed to coapt. The tumour was excised and the patient had complete relief of symptoms.
3. Discussion Obstruction to both superior and inferior vena cavae in this patient produced right-sided inflow
obstruction. This was due to the enormous size of the tumour leaving little room for venous return. This was also the cause of right-sided outflow obstruction. To the best of our knowledge, obstruction to both right-sided inflow as well as outflow due to a myxoma has not been described. This manifestation of myxoma is unusual because: (a) only 8–20% of myxoma occur in RA [2]; (b) among them, myxoma that occupies the entire RA and RV is still rare; (c) further, myxoma presenting as superior as well as inferior vena caval obstruction is very uncommon. Thus myxoma manifesting as right-sided inflow as well as outflow obstruction is virtually unknown. Two-dimensional echocardiography (especially transoesophageal) provides adequate information regarding size, mobility, attachment and relation to other structures, so that invasive techniques are often not required. Surgery results in complete cure.
References [1] Charuzi Y, Bolger A, Beeder C, Lew AS. A new echocardiographic classification of left atrial myxoma. Am J Cardiol 1985;55:614–5. [2] Blanchard DG, DeMaria AN. Cardiac and extracardiac masses: echocardiographic evaluation. In: Skorton DJ, Schelbert HR, Wolf GL, Brundage BH, Braunwald E, editors, 2nd ed., Cardiac imaging, vol. 1, Philadelphia, PA: Saunders, 1996, p. 469.
Letter to the Editor
Myxoma producing right-sided inflow and outflow obstruction a, b K.M. Krishnamoorthy *, N.B. Desai a
b
Department of Cardiology, Sri Sathya Sai Institute of Higher Medical Sciences, Puttaparthi 515 134, India Department of Cardiac Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Puttaparthi 515 134, India Received 6 March 2001; accepted 6 March 2001
1. Introduction A huge myxoma occupied the entire right heart producing obstruction to both inflow and outflow on the right side. This uncommon manifestation of a common tumor has not been reported.
2. Case report A 25-year-old man presented with fatigue, fever and weight loss of 3 months duration. He had plethoric face and lips with oedema of face, neck, arms and legs. Veins were dilated and tortuous over the neck, arms and abdominal wall. Liver was enlarged. Anaemia and high sedimentation rate were present. There was a systolic murmur of right ventricular (RV) outflow tract obstruction. Transthoracic echocardiography showed a myxoma occupying the whole of the right atrium (RA) and RV. The tumour was class IV according to Charuzi’s criteria [1]. It had an ovoid shape with a smooth surface and pingpong movement with each cardiac cycle. RA and RV cavity were more than double the size of left atrium (LA) and left ventricle (LV), respectively. In spite of that, the available RA and RV cavity was diminished as the tumor occupied the whole of RA and RV. It encroached upon the orifices of both superior and inferior vena cavae. These were obstructed and *Corresponding author. Present address: SCTIMST, Trivandrum — 695 011, India. Tel.: 191-471-555532; fax: 191-471-446433. E-mail address: [email protected] (K.M. Krishnamoorthy).
dilated. There was pericardial effusion. The tumor also extended to the RV outflow tract producing severe obstruction with a peak Doppler gradient of 80 mmHg. Areas suggesting haemorrhage in the tumor were present. Transoesophageal echocardiography was done to improve definition of the tumor. It showed the slit-like available cavity of RA and RV (Fig. 1). Although LA and LV are only partly visible in the figure, their cavity is much less than that available in RA and RV. Extension of the tumor to the RV outflow tract producing obstruction was seen (Fig. 2). During surgery, the tumour was seen to
Fig. 1. Transoesophageal echocardiographic view. RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle. Pericardial effusion is seen.
0167-5273 / 01 / $ – see front matter 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 01 )00434-X
326
K.M. Krishnamoorthy, N.B. Desai / International Journal of Cardiology 79 (2001) 325 – 326
Fig. 2. Transoesophageal echocardiographic view. LA, left atrium; Ao, aorta; RVOT, right ventricular outflow tract.
occupy the whole of RA and RV. The tricuspid valve was normal but failed to coapt. The tumour was excised and the patient had complete relief of symptoms.
3. Discussion Obstruction to both superior and inferior vena cavae in this patient produced right-sided inflow
obstruction. This was due to the enormous size of the tumour leaving little room for venous return. This was also the cause of right-sided outflow obstruction. To the best of our knowledge, obstruction to both right-sided inflow as well as outflow due to a myxoma has not been described. This manifestation of myxoma is unusual because: (a) only 8–20% of myxoma occur in RA [2]; (b) among them, myxoma that occupies the entire RA and RV is still rare; (c) further, myxoma presenting as superior as well as inferior vena caval obstruction is very uncommon. Thus myxoma manifesting as right-sided inflow as well as outflow obstruction is virtually unknown. Two-dimensional echocardiography (especially transoesophageal) provides adequate information regarding size, mobility, attachment and relation to other structures, so that invasive techniques are often not required. Surgery results in complete cure.
References [1] Charuzi Y, Bolger A, Beeder C, Lew AS. A new echocardiographic classification of left atrial myxoma. Am J Cardiol 1985;55:614–5. [2] Blanchard DG, DeMaria AN. Cardiac and extracardiac masses: echocardiographic evaluation. In: Skorton DJ, Schelbert HR, Wolf GL, Brundage BH, Braunwald E, editors, 2nd ed., Cardiac imaging, vol. 1, Philadelphia, PA: Saunders, 1996, p. 469.