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European Journal of Echocardiography 2006 7(4):322-325; doi:10.1016/j.euje.2005.06.005
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Copyright © 2005, The European Society of Cardiology

The protective effect of mitral stenosis on the embolization of a free-floating left atrial myxoma

Ante Matanaa,*, Luka Zaputovica, Ognjen Simicb and Zrinka Matana Kastelanc

aDepartment of Internal Medicine, Division of Cardiology, Clinical Hospital Center Rijeka, HR 51000 Rijeka, T. Strizica 3, Croatia
bDepartment of Surgery, Division of Cardiac Surgery, Clinical Hospital Center Rijeka, HR 51000 Rijeka, T. Strizica 3, Croatia
cMedical School, University of Rijeka, HR 51000 Rijeka, Brace Branchetta 22, Croatia

Received 25 February 2005; received in revised form 19 May 2005; accepted after revision 1 June 2005.

* Corresponding author. Tel.: +385 51 218 059; fax: +385 51 218 059. interna-susak{at}kbc-rijeka.hr


   Abstract
Top
 Abstract
Introduction
 Case report
 Discussion
 References
 
Mitral stenosis associated with free left atrial myxoma is very rare. A free myxoma is life-threatening when incarcerated in the mitral orifice or if embolization of the whole tumor occurs. We report a case of a female patient with moderate mitral stenosis and a detached left atrial myxoma. The myxoma was spherical, solid and smooth-surfaced. Mitral stenosis prevented the exit of the tumor from the left atrium and a possible fatal outcome. The tumor was surgically removed and mitral commissurotomy was successfully performed. Histological analysis confirmed the diagnosis of myxoma.

Keywords: Mitral stenosis; Myxoma; Left atrium


   Introduction
Top
 Abstract
 Introduction
Case report
 Discussion
 References
 
Mitral stenosis (MS) is a manifestation of rheumatic heart disease, with characteristic valvular changes, left atrial (LA) enlargement, susceptibility to atrial fibrillation (AF) and a higher risk of systemic embolization. Patient's clinical and echocardiographic follow-up makes it possible to choose the appropriate pharmacological treatment and optimal time for surgical intervention.1 LA myxoma (LAM) is the most frequent primary neoplasm of the heart,2–4 with possible clinical consequences such as obstructive circulatory disturbances, embolic events or systemic symptoms.5,6 It is usually peduncular, spherical and solid, or polypoid and friable, when it is especially prone to embolization.6,7 The association of MS and LAM is rare.


   Case report
Top
 Abstract
 Introduction
 Case report
Discussion
 References
 
The patient was a 65-year-old woman with moderate MS and AF. The mitral valve area measured by continuous-wave Doppler was 1.4cm2. LA was enlarged (44mm). All other echocardiographic findings, including the left ventricular ejection fraction were normal. The patient was in permanent AF, was treated with verapamil, warfarin and low doses of furosemide, and was asymptomatic, with an average ventricular rate of 80beats/min. Six months before hospitalization she experienced progressive exercise intolerance and occasional dizziness with no fainting episodes. Echocardiography detected a free spherical and very mobile formation in LA (24x33mm) with a smooth surface, constantly changing position (Fig. 1A). The formation intermittently moved to the narrowed mitral orifice without prolapsing into the left ventricle (Fig. 1B), and in systole was pushed by the mitral leaflets back to the LA cavity. Differing from the typical motions of a peduncular LAM, the movement of this mass to the mitral orifice was not coincident with the cardiac cycle (Fig. 2). The conclusion was that it must be a LA ball thrombus or LAM with a broken stalk. Surgical removal of the LAM with mitral commissurotomy was then indicated and successfully performed (Fig. 3A). Surgery confirmed a free-floating tumor in the LA and detected a stalk fragment at the periphery of the fossa ovalis. Excision of the interatrial septum tissue was performed and the defect was closed. Histological analysis confirmed the diagnosis of LAM (Fig. 3B).


Figure 1
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  		Figure 1 Two-dimensional echocardiogram of a spherical myxoma in the left atrium close to the anterior mitral leaflet (A). In diastole the myxoma moves to the mitral orifice. Its exit into the left ventricle is prevented by mitral stenosis (B). LA, left atrium; LV, left ventricle; AO, aorta; RV, right ventricle.

 


Figure 2
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  		Figure 2 M-mode echocardiogram of the anterior mitral leaflet and left atrium. Irregular movements of the myxoma towards the mitral orifice is shown. IVS, interventricular septum; LVOT, left ventricular outflow tract; AML, anterior mitral leaflet; LA, left atrium; M, myxoma.

 


Figure 3
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  		Figure 3 Left atrial myxoma after surgery (A). Microscopy showing myxoma cells dispersed throughout the myxoid stroma (B).

 

   Discussion
Top
 Abstract
 Introduction
 Case report
 Discussion
References
 
LAM is rarely associated with MS, and only a few cases have been reported in the literature.8–16 In such circumstances, LAM may worsen the hemodynamics by additionally aggravating LA emptying into the left ventricle and/or partially obstructing the pulmonary veins.5,6 In the case of LAM peduncle rupture, lethal complications may be assumed, such as tumor embolization or its incarceration in the mitral orifice, similar to those described in patients with a free-floating ball thrombus in LA.17–19 However, such reports were not found in the literature.

MS may prevent the free myxoma from exiting the LA. These cases are rare and only one has been reported to date.20 Descriptions of free-floating ball thrombi in LA are more frequent,17–28 thus, when a free, extremely mobile mass is detected in LA, a free-floating thrombus is considered first. Transesophageal echocardiography is useful for differentiating a myxoma from a free-floating thrombus.13,16

Our patient presented with a spherical, solid, smooth-surfaced myxoma not prone to embolization, as in polypoid prolapsing tumors.6,7 The rupture of the peduncle released the tumor, but MS prevented its exit from LA and the incarceration of the myxoma in the mitral orifice. In the absence of MS, the myxoma would most likely pass through the mitral orifice and, due to its size, obstruct the aortic entrance.

The coexistence of two pathological conditions usually worsens the patient's prognosis. Fortunately for our patient, this did not occur. The protective effect of MS prevented the detached myxoma from exiting the LA.


   References
Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 

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This Article
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