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Pulmonary tumor embolism and right atrial myxoma detected by two-dimensional echocardiography
Volume Number
110 4
Brief
previously reported caseswhere an RA clot may have formed in the legs>‘:’ the extracardiac source of the clot was inferred but not proven, since a prior echo, not showing clot, was not available. If the significanceof the RA masshad been recognized immediately and our patient had been anticoagulated, would the outcome have been different? Table I provides someclues, which of coursemust be consideredtentative conclusionsbecausecasestudies tend to report the most florid casesrather than the most representative cases. Nevertheless, certain trends can be seenby simply summing the results acrossall studies. First, there were 13 of 31 (42%) successfuloutcomes, whereas 18 of 31 (58%) were unsuccessful,defined aspulmonary embolismand/or death. Second,whereasthe efficacy of anticoagulation was marginal in patients with RA thrombus (5 of 17 anticoagmated cases had a successful outcome vs one of six patients not anticoagulated), thrombectomy was associated with a successfuloutcome in seven of eight cases. Third, if one examinesonly those patients with an extracardiac source for their cardiac thrombus, in 9 of the 10 instances where anticoagulation was given, the outcome wasunsuccessful.Thus, it is likely that anticoagulation is ineffective in patients with right heart thrombi from an extracardiac sourceand that thrombectomy, if feasible in a given patient, is the treatment of choice for this condition. REFERENCES 1.
2. 3.
4.
5.
6.
Meltzer RS, Visser CA, Kan G, Roelandt J: Two-dimensional echocardiographic appearance of left ventricular thrombi with systemic emboli after myocardial infarction. Am J Cardiol 53:1511, 1984. Frandsen EH, Egeblad H, Mortensen SA: Transience of left ventricular thrombosis. Br Heart J 49:193, 1983. Bensaid J, Blanc P, Virot P: Rapid disappearance of left ventricular mass (presumed thrombus) in a patient with cardiomyopathy. Br Heart J 47:301, 1982. Rosenzweig MS, Nanda NC: Two-dimensional echocardiographic detection of circulating right atria1 thrombi. AM HEART J 103:435, 1982. Felner JM, Churchwell AL, Murphy DA: Right atria1 thromboemboli: Clinical, echocardiographic and pathophysiologic manifestations. J Am Co11 Cardiol 4:1041, 1984. Spirit0 P, Bellotti P, Chiarella F, Spagnolo S, Vecchio C: Right atria1 thrombus detected by two-dimensional echocardiography after acute pulmonary embolism. Am J Cardiol 54:467,
1984.
Whitford EG, Harper RW, Federman J, Skolen A, Anderson ST, Pitt A: Right atria1 thrombus simulating myxoma on M-mode echocardiography in a patient with pulmonary emboli. Aust NZ Med 12:543, 1982. 8. Starkey IR, de Bono DP: Echocardiographic identification of right-sided cardiac intracavitary thromboembolus in massive pulmonary embolism. Circulation 66:1322, 1982. 9. Stowers SA. Leiboff RH. Wasserman AG. Katz RJ. Bren GB. Hsu I: Rigbt ventricular thrombus formation inassociation with acute myocardial infarction: Diagnosis by 2-dimensional echocardiography. Am J Cardiol 52:912, 1983. 10. Redish GA, Anderson AL: Echocardiographic diagnosis of right atria1 thromboembolism. J Am Co11 Cardiol 1:1167, 1983. 11. Ouyang P, Camara EJ, Jain A, Richman PS, Shapiro EP: Intracavitary thrombi in the right heart associated with multiple pulmonary emboli. Report of two patients. Chest 84:296, 1983. I.
12. 13.
14. 15.
16.
17. 18.
19.
20. 21.
39 .,-.
23.
Communications
881
Arvan S, DuBois B: M-mode and two-dimensional echocardiography of pulmonary emboli. JCU lO:l’i’i, 1982. Shiu MF, Abrams LD: Echocardiographic features of free floating thrombus mimicking right ventricular myxoma. Br Heart J 49:612, 1983. van Kuyk M, Mols P, Englert M: Right atria1 thrombus leading to pulmonary embolism. Br Heart J 51:462. 1984. Kessler KM, Mallon SM, Bolooki H, Myerburg RJ: Pedunculated right ventricular thrombus due to repeated chest trauma. AM HEART J 102: 1064, 1981. Formolo JM, Giraldo A, Shors CM: Fatal pulmonary embolism from massive right atria1 thrombus postcoronary artery bypass surgery.AM HEART J 101:510, 1981. Woolridge JD, Healey J: Echocardiographic diagnosis of right ventricular thromboembolism. AM HEART J 106:590, 1983. Come PC: Transient right atria1 thrombus during acute myocardial infarction: Diagnosis by echocardiography. Am J Cardiol 51:1228, 1983. Stern MJ, Cohen MV, Fish B, Rosenthal R. Clinical presentation and non-invasive diagnosis of right heart masses. Br Heart J 46:552, 1981. Covarrubias EA, Sheikh MU, Fox LM: Echocardiography and pulmonary embolism. Ann Intern Med 67:720, 1977. Panidis IP, Manno BV, Kotler MN, Mintz GS: Right atria1 thromboembolus: Echocardiographic detection in patient with fatal pulmonary embolism. J Cardiovasc Illtrasonography 2:337, 1983. Nestico PF, Panidis IP, Kotler MN, Mmtz GS. Ross J: Surgical removal of right atria1 thromboemholus detected by two-dimensional echocardiography in pulmonary embolism. AM HEART J 107:1278, 1984. Saner HE, Asinger RW, Daniel JA, Elsperger KJ: Two dimensional echocardiographic detection of right-sided cardiac intracavitary thromboembolus with pulmonary embolism. J Am Co11 Cardiol4:1294. 1984.
Pulmonary tumor embolism and right atrial myxoma detected by two-dimensional echocardiography H. Keller, M.D., B. Stegaru, M.D., J. Buss, M.D., K. Genth, M.D., and D. Heene, M.D. Heidelberg,
W. Germany
The occurrenceof peripheral emboli is relatively common and well documentedwith left atria1 myxoma.’ Therefore, it is not surprising that right atrial myxoma should give rise to pulmonary emboli. The associationof pulmonary emboli and right atria1 myxoma has been recognized at autopsy for many years.*The clinical diagnosisof pulmonary tumor embolismis lesswell documented,3and only a few casesof tumor pulmonary embolectomy have been reported.“ A 20-year-old man with homocystinuria diagnosed at age 6 treated with a methionine-restricted diet (without responseto oral supplementsof pyridoxine), wasadmitted to our hospital with suspecteddiagnosisof tuberculosis. At age 10, following an appendectomy, he had an acute From the First Medical Clinic Mannheim, University of Heidelberg. Reprint requests: Helmut Keller, M.D., 1. Medizinlsche Klinik, Klinikum Mannheim der Universit&t Heidelberg. Theodor-Kutzer-lifer 30, D-6800 Mannheim 1. W. Germany.
October,
882
Brief Communications
American
Heart
1985 Journal
Fig. 1. A, Apical four-chamber view, demonstrating a right atria1 myxoma (MYX) attached to the free wall of the right atrium (RA), prolapsing acrossthe tricuspid valve in diastole. B, M-mode recording of the tricuspid valve showinga massof echoesproduced by right atrial myxoma (MYX), appearing with a lag phase between the tricuspid leaflet in diastole. RV = right ventricle; LV = left ventricle; LA = left atrium.
occlusion of the right superficial femoral vein, which was treated with heparin. Since then the patient has been treated with dipyridamole (25 mg, 4 times daily) and acetylsalicylic acid (500 mg, twice daily). The patient had been in good health until 3 days previously, when he complained of left thoracic pain, hemoptysis, and moderate dyspnea. On admission the pulse rate was regular, 92/min, and the blood pressurewas 110/70 mm Hg. The apicai pulse was normal. Auscultation revealed no heart murmurs, normal heart sounds,no “tumor plop,” and the breath sounds of the left lung were diminished. There were no signs of heart failure and no clinical features of deep-vein thrombosis. The patient showedtypical signsof homocystinuria: height 190cm, weight 62 kg, long extremities, kyphoscoliosis, mild mental deficiency, dislocated lenses,and aphakia of the right side due to removal of a
dislocated lens. The ECG documented sinus rhythm without signsof right ventricular strain. The chest x-ray examination showed no cardiomegaly and no specific chamber enlargement, but a slight pleural effusion on the left side. Real-time cross-sectional scanning was performed, using a 3.5 MHz, go-degreephased array system (Varian 3400 R). The M-mode and two-dimensional echocardiogram (2DE) showed a wide aortic root (45 mm) and a holosystolic mitral valve prolapse. In the region of the right ventricular cavity, there were abnormal bands of echoesshowing systolic and diastolic motion. The apical four-chamber view confirmed the presence of a spaceoccupying lesion without the right atrium which was highly mobile and prolapsed acrossthe tricuspid valve (Fig. 1, A and B). The mobile tumor was definitely
Volume Number
110 4
Brief
Communications
383
2. A, Two-dimensional suprasternal view showing the aortic arch (AO) and the right pulmonary artery (PA), which is partially occludedby a tumor embolus(TU). B, M-mode registration demonstrating the subtotal occlusion of the right pulmonary artery (PA) by a tumor mass (TU). LA = left atrium; - = brachiocephalic vessels. Fig.
attached to the free wall of the right atrium. Suprasternal approach revealed a partial occlusion of the right pulmonary artery, which wasdemonstrated by M-mode and 2DE (Fig. 2, A and B) The motion of the pulmonic valve indicated pulmonary hypertension: reduced EF slope, diminished a wave, midsystolic closure, and fluttering of the pulmonic valve. Left sternal minor axis views of the right ventricular outflow portion and the main pulmonary artery showeda large masswhich blocked the left pulmonary artery and partially occluded the right pulmonary artery (Fig. 3). The diagnosisof a tumor embolization causedby right atrial myxoma was made by echocardiography and was confirmed by CT scan, digital subtraction angiography, and pulmonary perfusion scan, showing no perfusion of the entire left lung and reduced perfusion of the right lung. The tumor embolus,which occluded the orifice of the left
pulmonary trunk and part of the right pulmonary artery, was surgically removed and the right atria1 myxoma was exised with a surrounding cuff of the free wall of the right atrium. The postoperative course was uneventful. Histologic examination of the tumor confirmed the diagnosisof a myxoma. At review 2 months later the patient was asymptomatic. Mobile thrombi in the right atrium have been detected by 2DE in patients with pulmonary embolism.5In rare casesa thrombus in the right pulmonary artery could be demonstrated by echocardiography. This may be the first reported caseof a pulmonary tumor embolus stemming from a right atria1 myxoma diagnosedby echocardiograph. REFERENCES
1. Bulkley review.
BH, Hutchins GM: Atria1 AM HEART J 97:639, 1979.
myxoma:
A fifty
year
884
Brief
American
Communications
October, 1985 Heart Journal
Fig. 3. Left sternal minor axis view showing the right ventricular outflow portion, the main pulmonary trunk (PA), and a tumor embolus(TV) blocking the left pulmonary artery (L) and partially occluding the right pulmonary artery (R). A0 = aortic root.
2. 3. 4.
5.
6.
Heath D, Mackinnon J: Pulmonary hypertension due to myxoma of the right atrium. AM HEART J 68:227, 1964. Collins HA, Collins IS: Clinical experience with cardiac myxoma. Ann Thorac Surg 13:450, 1972. Keenan DJM, Morton P, O’Kane HO: Right atria1 myxoma and pulmonary embolism. Rational basis for investigation and treatment: Br Heart J 48:510, 1982. Nestico PF. Panidis IP. Kotler MN. Mintz GS. Ross J: Surgical removal of right’atrial thromboembolus detected by two-dimensional echocardiography in pulmonary embolism. AM HEART J 107:1278, 1984. Erbel R, Schweizer P, Effert S: Direkter ein-und zweidimensionaler Nachweis einer akuten Lungenembolie. Dtsch Med Wochenschr 106:179, 1981.
Metastatic atrium
carcinoma
involving
the left
Roberto M. Lang, M.D., Kenneth M. Borow, M.D., and Alexander Neumann, B.S. Chicago, Ill.
The advent of two-dimensional echocardiographic imaging has made possiblethe antemortem diagnosisof intracardiac tumors. Although metastatic tumors to the heart or pericardium occur 16 to 40 times more frequently than primary tumors,’ most intracavitary tumors are of primary origin.2 The most common of these primary cardiac tumors is the atrial myxoma. In contrast, metastases usually occur to the pericardium and myocardium and are From the Cardiology Section, Department of Medicine, and Department of Surgery, The University of Chicago. Reprint requests: Roberto M. Lang, M.D., Cardiology Section, Department of Medicine, The University of Chicago Medical Center, 950 East 59th St., Box 44, Chicago, IL 60637.
only rarely intracavitary, involving either valves or endocardium. As will be shown in this report, the clinical and echocardiographicpresentation of metastatic and primary cardiac tumors may closely mimic one another. A 54-year-old black female was admitted to The University of Chicago Medical Center with complaints of lethargy, paroxysmal dyspnea in part related to body position, fever, weight loss, anorexia, and a productive cough. Past medical history was remarkable for a uterine leiomyosarcomadiagnosed5 years earlier. There was no evidence of metastatic spread. Treatment consisted of a hysterectomy. At the time of this admission,blood pressure was 134/76 mm Hg, heart rate was 114 bpm, and respiratory rate was 27 per minute. Auscultation of the lungs revealed decreasedbreath soundsat the left base. Cardiac examination disclosed a diminished first heart sound and an early diastolic rumble audible over the left precordium. No further murmurs were noted. Chest roentgenogram demonstrated a posterior mediastinal mass extending from the left hilum to the left lower lobe. Two-dimensional echocardiographic study revealed a large (approximately 10 cm X 3 cm), multilobed, extremely mobile mass(Fig. 1,A). In the apical four-chamber view, the intracardiac mass appeared to originate from the posterior rather than the medial aspect of the left atrium. During diastole, the mass extended nearly to the left ventricular apex while filling over 80% of the mitral valve orifice. The mitral valve leaflets appeared intrinsically normal. Due to the large size of the massand its presence in the left ventricle during all portions of the cardiac cycle, an adequate Doppler echocardiographic study could not be obtained. The patient continued to demonstrate signs of left ventricular inflow tract obstruction. Surgical resection of left atria1 and pulmonary masseswas performed without further diagnostic workup. The excised cardiac tumor (Fig. 1, B) was 12 cm X 3 cm X 2 cm in size, and
110 4
Brief
previously reported caseswhere an RA clot may have formed in the legs>‘:’ the extracardiac source of the clot was inferred but not proven, since a prior echo, not showing clot, was not available. If the significanceof the RA masshad been recognized immediately and our patient had been anticoagulated, would the outcome have been different? Table I provides someclues, which of coursemust be consideredtentative conclusionsbecausecasestudies tend to report the most florid casesrather than the most representative cases. Nevertheless, certain trends can be seenby simply summing the results acrossall studies. First, there were 13 of 31 (42%) successfuloutcomes, whereas 18 of 31 (58%) were unsuccessful,defined aspulmonary embolismand/or death. Second,whereasthe efficacy of anticoagulation was marginal in patients with RA thrombus (5 of 17 anticoagmated cases had a successful outcome vs one of six patients not anticoagulated), thrombectomy was associated with a successfuloutcome in seven of eight cases. Third, if one examinesonly those patients with an extracardiac source for their cardiac thrombus, in 9 of the 10 instances where anticoagulation was given, the outcome wasunsuccessful.Thus, it is likely that anticoagulation is ineffective in patients with right heart thrombi from an extracardiac sourceand that thrombectomy, if feasible in a given patient, is the treatment of choice for this condition. REFERENCES 1.
2. 3.
4.
5.
6.
Meltzer RS, Visser CA, Kan G, Roelandt J: Two-dimensional echocardiographic appearance of left ventricular thrombi with systemic emboli after myocardial infarction. Am J Cardiol 53:1511, 1984. Frandsen EH, Egeblad H, Mortensen SA: Transience of left ventricular thrombosis. Br Heart J 49:193, 1983. Bensaid J, Blanc P, Virot P: Rapid disappearance of left ventricular mass (presumed thrombus) in a patient with cardiomyopathy. Br Heart J 47:301, 1982. Rosenzweig MS, Nanda NC: Two-dimensional echocardiographic detection of circulating right atria1 thrombi. AM HEART J 103:435, 1982. Felner JM, Churchwell AL, Murphy DA: Right atria1 thromboemboli: Clinical, echocardiographic and pathophysiologic manifestations. J Am Co11 Cardiol 4:1041, 1984. Spirit0 P, Bellotti P, Chiarella F, Spagnolo S, Vecchio C: Right atria1 thrombus detected by two-dimensional echocardiography after acute pulmonary embolism. Am J Cardiol 54:467,
1984.
Whitford EG, Harper RW, Federman J, Skolen A, Anderson ST, Pitt A: Right atria1 thrombus simulating myxoma on M-mode echocardiography in a patient with pulmonary emboli. Aust NZ Med 12:543, 1982. 8. Starkey IR, de Bono DP: Echocardiographic identification of right-sided cardiac intracavitary thromboembolus in massive pulmonary embolism. Circulation 66:1322, 1982. 9. Stowers SA. Leiboff RH. Wasserman AG. Katz RJ. Bren GB. Hsu I: Rigbt ventricular thrombus formation inassociation with acute myocardial infarction: Diagnosis by 2-dimensional echocardiography. Am J Cardiol 52:912, 1983. 10. Redish GA, Anderson AL: Echocardiographic diagnosis of right atria1 thromboembolism. J Am Co11 Cardiol 1:1167, 1983. 11. Ouyang P, Camara EJ, Jain A, Richman PS, Shapiro EP: Intracavitary thrombi in the right heart associated with multiple pulmonary emboli. Report of two patients. Chest 84:296, 1983. I.
12. 13.
14. 15.
16.
17. 18.
19.
20. 21.
39 .,-.
23.
Communications
881
Arvan S, DuBois B: M-mode and two-dimensional echocardiography of pulmonary emboli. JCU lO:l’i’i, 1982. Shiu MF, Abrams LD: Echocardiographic features of free floating thrombus mimicking right ventricular myxoma. Br Heart J 49:612, 1983. van Kuyk M, Mols P, Englert M: Right atria1 thrombus leading to pulmonary embolism. Br Heart J 51:462. 1984. Kessler KM, Mallon SM, Bolooki H, Myerburg RJ: Pedunculated right ventricular thrombus due to repeated chest trauma. AM HEART J 102: 1064, 1981. Formolo JM, Giraldo A, Shors CM: Fatal pulmonary embolism from massive right atria1 thrombus postcoronary artery bypass surgery.AM HEART J 101:510, 1981. Woolridge JD, Healey J: Echocardiographic diagnosis of right ventricular thromboembolism. AM HEART J 106:590, 1983. Come PC: Transient right atria1 thrombus during acute myocardial infarction: Diagnosis by echocardiography. Am J Cardiol 51:1228, 1983. Stern MJ, Cohen MV, Fish B, Rosenthal R. Clinical presentation and non-invasive diagnosis of right heart masses. Br Heart J 46:552, 1981. Covarrubias EA, Sheikh MU, Fox LM: Echocardiography and pulmonary embolism. Ann Intern Med 67:720, 1977. Panidis IP, Manno BV, Kotler MN, Mintz GS: Right atria1 thromboembolus: Echocardiographic detection in patient with fatal pulmonary embolism. J Cardiovasc Illtrasonography 2:337, 1983. Nestico PF, Panidis IP, Kotler MN, Mmtz GS. Ross J: Surgical removal of right atria1 thromboemholus detected by two-dimensional echocardiography in pulmonary embolism. AM HEART J 107:1278, 1984. Saner HE, Asinger RW, Daniel JA, Elsperger KJ: Two dimensional echocardiographic detection of right-sided cardiac intracavitary thromboembolus with pulmonary embolism. J Am Co11 Cardiol4:1294. 1984.
Pulmonary tumor embolism and right atrial myxoma detected by two-dimensional echocardiography H. Keller, M.D., B. Stegaru, M.D., J. Buss, M.D., K. Genth, M.D., and D. Heene, M.D. Heidelberg,
W. Germany
The occurrenceof peripheral emboli is relatively common and well documentedwith left atria1 myxoma.’ Therefore, it is not surprising that right atrial myxoma should give rise to pulmonary emboli. The associationof pulmonary emboli and right atria1 myxoma has been recognized at autopsy for many years.*The clinical diagnosisof pulmonary tumor embolismis lesswell documented,3and only a few casesof tumor pulmonary embolectomy have been reported.“ A 20-year-old man with homocystinuria diagnosed at age 6 treated with a methionine-restricted diet (without responseto oral supplementsof pyridoxine), wasadmitted to our hospital with suspecteddiagnosisof tuberculosis. At age 10, following an appendectomy, he had an acute From the First Medical Clinic Mannheim, University of Heidelberg. Reprint requests: Helmut Keller, M.D., 1. Medizinlsche Klinik, Klinikum Mannheim der Universit&t Heidelberg. Theodor-Kutzer-lifer 30, D-6800 Mannheim 1. W. Germany.
October,
882
Brief Communications
American
Heart
1985 Journal
Fig. 1. A, Apical four-chamber view, demonstrating a right atria1 myxoma (MYX) attached to the free wall of the right atrium (RA), prolapsing acrossthe tricuspid valve in diastole. B, M-mode recording of the tricuspid valve showinga massof echoesproduced by right atrial myxoma (MYX), appearing with a lag phase between the tricuspid leaflet in diastole. RV = right ventricle; LV = left ventricle; LA = left atrium.
occlusion of the right superficial femoral vein, which was treated with heparin. Since then the patient has been treated with dipyridamole (25 mg, 4 times daily) and acetylsalicylic acid (500 mg, twice daily). The patient had been in good health until 3 days previously, when he complained of left thoracic pain, hemoptysis, and moderate dyspnea. On admission the pulse rate was regular, 92/min, and the blood pressurewas 110/70 mm Hg. The apicai pulse was normal. Auscultation revealed no heart murmurs, normal heart sounds,no “tumor plop,” and the breath sounds of the left lung were diminished. There were no signs of heart failure and no clinical features of deep-vein thrombosis. The patient showedtypical signsof homocystinuria: height 190cm, weight 62 kg, long extremities, kyphoscoliosis, mild mental deficiency, dislocated lenses,and aphakia of the right side due to removal of a
dislocated lens. The ECG documented sinus rhythm without signsof right ventricular strain. The chest x-ray examination showed no cardiomegaly and no specific chamber enlargement, but a slight pleural effusion on the left side. Real-time cross-sectional scanning was performed, using a 3.5 MHz, go-degreephased array system (Varian 3400 R). The M-mode and two-dimensional echocardiogram (2DE) showed a wide aortic root (45 mm) and a holosystolic mitral valve prolapse. In the region of the right ventricular cavity, there were abnormal bands of echoesshowing systolic and diastolic motion. The apical four-chamber view confirmed the presence of a spaceoccupying lesion without the right atrium which was highly mobile and prolapsed acrossthe tricuspid valve (Fig. 1, A and B). The mobile tumor was definitely
Volume Number
110 4
Brief
Communications
383
2. A, Two-dimensional suprasternal view showing the aortic arch (AO) and the right pulmonary artery (PA), which is partially occludedby a tumor embolus(TU). B, M-mode registration demonstrating the subtotal occlusion of the right pulmonary artery (PA) by a tumor mass (TU). LA = left atrium; - = brachiocephalic vessels. Fig.
attached to the free wall of the right atrium. Suprasternal approach revealed a partial occlusion of the right pulmonary artery, which wasdemonstrated by M-mode and 2DE (Fig. 2, A and B) The motion of the pulmonic valve indicated pulmonary hypertension: reduced EF slope, diminished a wave, midsystolic closure, and fluttering of the pulmonic valve. Left sternal minor axis views of the right ventricular outflow portion and the main pulmonary artery showeda large masswhich blocked the left pulmonary artery and partially occluded the right pulmonary artery (Fig. 3). The diagnosisof a tumor embolization causedby right atrial myxoma was made by echocardiography and was confirmed by CT scan, digital subtraction angiography, and pulmonary perfusion scan, showing no perfusion of the entire left lung and reduced perfusion of the right lung. The tumor embolus,which occluded the orifice of the left
pulmonary trunk and part of the right pulmonary artery, was surgically removed and the right atria1 myxoma was exised with a surrounding cuff of the free wall of the right atrium. The postoperative course was uneventful. Histologic examination of the tumor confirmed the diagnosisof a myxoma. At review 2 months later the patient was asymptomatic. Mobile thrombi in the right atrium have been detected by 2DE in patients with pulmonary embolism.5In rare casesa thrombus in the right pulmonary artery could be demonstrated by echocardiography. This may be the first reported caseof a pulmonary tumor embolus stemming from a right atria1 myxoma diagnosedby echocardiograph. REFERENCES
1. Bulkley review.
BH, Hutchins GM: Atria1 AM HEART J 97:639, 1979.
myxoma:
A fifty
year
884
Brief
American
Communications
October, 1985 Heart Journal
Fig. 3. Left sternal minor axis view showing the right ventricular outflow portion, the main pulmonary trunk (PA), and a tumor embolus(TV) blocking the left pulmonary artery (L) and partially occluding the right pulmonary artery (R). A0 = aortic root.
2. 3. 4.
5.
6.
Heath D, Mackinnon J: Pulmonary hypertension due to myxoma of the right atrium. AM HEART J 68:227, 1964. Collins HA, Collins IS: Clinical experience with cardiac myxoma. Ann Thorac Surg 13:450, 1972. Keenan DJM, Morton P, O’Kane HO: Right atria1 myxoma and pulmonary embolism. Rational basis for investigation and treatment: Br Heart J 48:510, 1982. Nestico PF. Panidis IP. Kotler MN. Mintz GS. Ross J: Surgical removal of right’atrial thromboembolus detected by two-dimensional echocardiography in pulmonary embolism. AM HEART J 107:1278, 1984. Erbel R, Schweizer P, Effert S: Direkter ein-und zweidimensionaler Nachweis einer akuten Lungenembolie. Dtsch Med Wochenschr 106:179, 1981.
Metastatic atrium
carcinoma
involving
the left
Roberto M. Lang, M.D., Kenneth M. Borow, M.D., and Alexander Neumann, B.S. Chicago, Ill.
The advent of two-dimensional echocardiographic imaging has made possiblethe antemortem diagnosisof intracardiac tumors. Although metastatic tumors to the heart or pericardium occur 16 to 40 times more frequently than primary tumors,’ most intracavitary tumors are of primary origin.2 The most common of these primary cardiac tumors is the atrial myxoma. In contrast, metastases usually occur to the pericardium and myocardium and are From the Cardiology Section, Department of Medicine, and Department of Surgery, The University of Chicago. Reprint requests: Roberto M. Lang, M.D., Cardiology Section, Department of Medicine, The University of Chicago Medical Center, 950 East 59th St., Box 44, Chicago, IL 60637.
only rarely intracavitary, involving either valves or endocardium. As will be shown in this report, the clinical and echocardiographicpresentation of metastatic and primary cardiac tumors may closely mimic one another. A 54-year-old black female was admitted to The University of Chicago Medical Center with complaints of lethargy, paroxysmal dyspnea in part related to body position, fever, weight loss, anorexia, and a productive cough. Past medical history was remarkable for a uterine leiomyosarcomadiagnosed5 years earlier. There was no evidence of metastatic spread. Treatment consisted of a hysterectomy. At the time of this admission,blood pressure was 134/76 mm Hg, heart rate was 114 bpm, and respiratory rate was 27 per minute. Auscultation of the lungs revealed decreasedbreath soundsat the left base. Cardiac examination disclosed a diminished first heart sound and an early diastolic rumble audible over the left precordium. No further murmurs were noted. Chest roentgenogram demonstrated a posterior mediastinal mass extending from the left hilum to the left lower lobe. Two-dimensional echocardiographic study revealed a large (approximately 10 cm X 3 cm), multilobed, extremely mobile mass(Fig. 1,A). In the apical four-chamber view, the intracardiac mass appeared to originate from the posterior rather than the medial aspect of the left atrium. During diastole, the mass extended nearly to the left ventricular apex while filling over 80% of the mitral valve orifice. The mitral valve leaflets appeared intrinsically normal. Due to the large size of the massand its presence in the left ventricle during all portions of the cardiac cycle, an adequate Doppler echocardiographic study could not be obtained. The patient continued to demonstrate signs of left ventricular inflow tract obstruction. Surgical resection of left atria1 and pulmonary masseswas performed without further diagnostic workup. The excised cardiac tumor (Fig. 1, B) was 12 cm X 3 cm X 2 cm in size, and