European Journal of Echocardiography 2008 9(1):84-85; doi:10.1016/j.euje.2007.01.007
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org.
Left ventricular myxoma originating from the interventricular septum and obstructing the left ventricular outflow tract
Enrico Natale*,
Giovanni Minardi,
Giovanni Casali,
Giovanni Pulignano and
Francesco Musumeci
Dipartimento Cardiovascolare, Ospedale S. Camillo, C.ne Gianicolense 87, Roma 00152, Italy
Received 20 August 2006; accepted after revision 20 January 2007; online publish-ahead-of-print 24 March 2007.
* Corresponding author. Via Mario Fascetti 62, 00136 Rome, Italy. Tel: +39 3483122566, +39 06 35347593, +39 06 58704419; fax: +39 06 58704361. E-mail address: enrico.natale{at}flashnet.it
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Abstract
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In a 60-year-old woman with episodic exertional faintness, a
large left ventricular (LV) myxoma attached by a pedicle to
the apical interventricular septum and prolapsing through the
LV outflow tract and the aortic valve causing a severe obstruction
was found by echocardiography. Early surgical excision was successfully
performed using the transaortic approach.
Keywords: Left ventricular myxoma; Subaortic obstruction; Echocardiography; Transaortic surgical excision
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Case report
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A 60-year-old woman presented with a history of exertional faintness.
She had a harsh systolic murmur in the third and fourth intercostal
spaces, left sternal edge, and in the second right intercostal
space. Transthoracic echocardiography demonstrated a large pedunculated
pear-shaped mass (75
x 45 mm in diameter) in the left ventricular
(LV) cavity, attached to the apical portion of the interventricular
septum, extending into the outflow tract with a systolic prolapse
through the aortic valve
(Figure 1A–D). A severe
outflow obstruction, with peak and mean systolic pressure gradients
equal to 120 and 69 mmHg, respectively, was found
(Figure 1E).
LV function was normal. The other cardiac valves and cavities
were free of lesions. Angiographic study showed normal coronary
arteries.
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Figure 1 Echocardiography in the apical four-chamber view (A, diastole; B, systole) demonstrated a large mass in the left ventricular cavity attached to the distal septum by a pedicle (arrow). The tumor protruded through the aortic valve in systole (D) with a severe obstruction, as shown in the apical five-chamber view (C, diastole; D, systole) and in the continuous-wave Doppler recording of the left ventricular outflow tract (E).
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Surgical excision of the LV myxoma was performed under normothermic
cardiopulmonary bypass by way of a median sternotomy. After
oblique aortotomy a huge fragile jelly-like myxoma became visible
in the LV cavity through the aortic cusps. The gelatinous tissue
appeared as yellow-brownish myxoid stroma. The tumor was attached
by a pedicle, with a square centimeter insertion area, to the
apical interventricular septum next to the base of the anterolateral
papillary muscle. The LV myxoma was completely removed by fragmentation
and careful suction. The pedicle was finally detached from the
distal septum by accurate excision under direct vision.
Figure 2 shows the reconstruction of the tumor with the fibrous pedicle.
The postoperative course of the patient was uneventful. Histopathologic
examination was consistent with the diagnosis of a myxoma.
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Discussion
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LV localization of a myxoma is extremely rare, accounting for
2.5–4% of all cases.
1 To the authors' knowledge this is
the first case of severe LV outflow tract obstruction due to
a LV myxoma originating from the interventricular septum. Only
a few cases have been reported in myxomas originating from the
mitral valve.
2–4 The shape, the extension, the site of
attachment, the involvement of valve leaflets and the functional
obstruction to LV outflow tract could promptly and easily be
assessed by echocardiography. This myxoma required urgent resection.
The patient was at an increased risk of sudden death and systemic
embolization due to the systolic prolapse of the mass through
the aortic valve with severe obstruction, the characteristics
of the myxoma, and the high pressure within the left ventricle
during systole.
2 The mass was removed by using the transaortic
approach in order to avoid a left ventriculotomy and its potential
complications. This approach allowed the complete resection
of the LV myxoma.
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Supplementary material
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Supplementary data associated with this article can be found in the online version.
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References
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- Kirklin JW, Barratt-Boyes BG, Cardiac tumor. Cardiac Sugery—Kirklin JW, Barratt-Boyes BG, eds. (1993) . New York: Churchill Livingstone. 1635–53.
- Keeling IM, Oberwalder P, Anelli-Monti M, Schuchlenz H, Demel U, Tilz GP, Rehak P, Rigler B, et al. Cardiac myxomas: 24 years of experience in 49 patients. Eur J Cardiothorac Surg (2002) 22:971–7.[Abstract/Free Full Text]
- Keeling IM, Oberwalder P, Schuchlenz H, Anelli-Monti M, Rigler B. Left ventricular outflow tract obstruction due to valve myxoma. Ann Thorac Surg (2000) 69:1590–1.[Abstract/Free Full Text]
- Choi BW, Ryu SJ, Chang BC, Choe KO. Myxoma attached to both atrial and ventricular sides of the mitral valve: report of a case and review of 31 cases of mitral myxoma. Int J Cardiovasc Imaging (2001) 17:411–6.[CrossRef][Web of Science][Medline]
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Abstract
Case report