European Journal of Echocardiography 2003 4(4):339-341; doi:10.1016/S1525-2167(03)00036-2
© 2003 by European Society of Cardiology
Copyright © 2003, The European Society of Cardiology
Left Ventricular Outflow Tract Myxoma
Y. Gurlertop1,
M. Yilmaz1,
F. Erdogan2,
M. Acikel1 and
N. Kose
1Department of Cardiology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
2Department of Pathology, Faculty of Medicine, Atatürk University, Erzurum, Turkey
Received 31 January 2003; received in revised form 8 April 2003; accepted after revision 9 April 2003.
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Abstract
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This article reports a left ventricular outflow tract (LVOT)
myxoma, presenting with peripheral embolus, in a 90-year-old
patient during the follow-up due to ischemic heart disease.
Among LVOT myxomas, which are usually very rare and most likely
to present with manifestations due to obstruction, this is the
first case presenting with peripheral embolus. In this study,
diagnosis was based on the histopathological evaluation of the
embolectomy material. The report emphasizes the importance of
evaluation of the embolectomy material in appropriate patients
who present with peripheral emboli, and where an intracardiac
mass is suspected.
Keywords: myxoma; intracardiac mass
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Introduction
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Cardiac myxomas are the most common primary tumors of the heart.
Most cardiac tumors are localized in left atrium (75%), followed
by right atrium (18%), and the remaining, in ventricles
[1].
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Case Report
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A 90-year-old woman, admitted for evaluation due to recent-onset
epigastric pain, nausea and vomiting, had a history of anterior
myocardial infarction (MI) (2 years ago), upper gastrointestinal
tract bleeding (1 year ago) and chronic anemia. She had been
taking no medication. Findings on physical examination were
as follows: rhythmic pulse, 60 bpm; blood pressure, 100/60 mmHg;
an apical pan-systolic murmur, 3/6; pale conjunctivas and palpable
peripheral pulses. Electrocardiogram (ECG) findings were: AV
block (3°); rate, 60/min; QRS axis, +90°; duration,
0.16 s and low voltage. Laboratory findings were: Hb, 6.3 gr;
leucocytes, 12,000/ml; troponin, T (+). She was hospitalized
due to acute MI without ST segment elevation. Unfractionated
heparin, lansoprazol and IV nitrates were initiated. Within
the second hour of hospitalization, she suffered from left leg
pain. On physical examination, the left leg was pale and the
popliteal and the further distal pulses were not palpable. Transthoracic
echocardiography was performed, as peripheral arterial embolus
was suspected. A 1.2
x0.8 cm inactive mass with same echogenity
as myocardium and with no evident pedicel structure was detected
on the left ventricular outflow tract (LVOT) (
Fig. 1). Additionally,
apical dyskinesia, left ventricular (LV) systolic dysfunction
(EF: 43%), mitral and aortic valve calcification, and moderate
mitral and tricuspidal insufficiency were detected on echocardiography.
A maximal velocity of 1.2 m/s was measured in LVOT via continuous
wave Doppler. No pathological findings were observed in LVOT
via color Doppler apart from a mild turbulence. Additional transesophageal
echocardiography was not planned because of the existing acute
coronary syndrome clinic. The previous medical records of the
patient regarding the echocardiography conducted 2 years ago
did not mention such a mass, however, we could not access the
original images of the echocardiography. Emergent embolectomy
was conducted. After the embolectomy, in contrast to distal
pulses, popliteal pulse was palpable. The patient died of cardiogenic
shock on day 3 of hospitalization. Autopsy was not performed
as the family did not grant permission. Histopathological evaluation
of embolectomy material revealed myxoma (
Fig. 2).
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Discussion
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Myxomas are rarely seen in the LV. Reviewing the literature
revealed 78 cases of isolated LV myxoma. LVOT is the least likely
region they emerge from. To date, three myxomas localized on
LVOT have been reported
[2–4]. Our case is the fourth case
of myxoma localized on LVOT and our patient is the oldest among
all. Fifty percent of the myxomas localized in the LV cause
emboli
[2]. One of the most important features of our case is
that among all the LVOT myxomas, our case is the first case,
presenting with manifestations due to embolus. LVOT myxomas,
reported previously, had presented with manifestations due to
obstruction. Localization of other tumoral settlements within
LVOT is rare. The most common neoplasy seen in this region consists
of metastatic tumors. The most common primary tumors are rhabdomyoma
(six cases), myxoma (four cases) and papillary fibroelastoma
(three cases). Primary malignant tumors have been reported in
two cases. Other important feature of our case is that the histological
diagnosis was based on the embolectomy material. Use of embolectomy
material for diagnosis of intracardiac masses is a previously
recognized method
[5]. Due to their brittle structure, myxomas
result in tumoral emboli. In our case, the embolectomy material
consisted mainly of thrombus, however, composed of very little
myxoma tissue. Detachment of the thrombi together with the part
they are attached to is considered to be the cause of the emboli.
This case proves that macroscopic evaluation of the embolectomy
material can be misleading and that the embolectomy material
should be evaluated pathologically. The treatment of LVOT myxomas
is surgical
[2–4]. In our case, clinical course and additional
medical problems did not allow surgical interventions. Successful
surgical excisions were conducted in other LVOT myxomas, and
no recurrences were reported.
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References
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- Collucci W.S., Schoen F.J. Heart disease. A textbook of cardiovascular medicine. In: 6th Edition—Braunwald E., Zipes D.P., Libby P., eds. (2001) W.B. Saunders. 1087–1822.
- Thongcharoen P., Laksanabunsong P., Thongtang V. Left ventricular outflow tract obstruction due to a left ventricular myxoma: a case report and review of the literature. J Med Assoc Thai (1997) 80(12):799–806.[Medline]
- Cis A., Fernandez Rostello E., Marticani R. Myxoma of the left ventricular outflow tract. An Esp Pediatr (2001) 55(1):80–82.[Medline]
- Tisma S., Todoric M., Ilic R., et al. Successful surgical removal of a cardiac myxoma from the left ventricular outflow tract. Vojnosanit Pregl (2001) 58(2):195–198.[Medline]
- Hanssens M., De Scheerder I., De Buyzere M., Clement D.L. Primary cardiac tumors: retrospective evaluation of 15 consecutive patients. Acta Cardiol (1988) 43(1):21–29.[Web of Science][Medline]
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Abstract
Introduction
