Transesophageal Echocardiography in Left Ventricular Myxoma

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Transesophageal Echocardiography in Left Ventricular Myxoma SAURABH GOEL, M.D., NITIN DESHPANDE, M.D., CHANDER VANJANI, M.D., PAWAN KUMAR, M.S., RAJESH SHETTY, M.D., and M E S H W A N I , M.D. Department of Cardiology, P.D. Hinduja National Hospital & Medical Research Center, Mumbai, India

A 40-year-old male patient was admitted with the history of repeated episodes of giddiness for 3 months without any history of syncope. Physical examination revealed a normal regular pulse and blood pressure. On cardiac examination, there was an ejection click and a short systolic murmur in the aortic area. The patient was investigated with the clinical suspicion of aortic valve disease. Transthoracic echocardiography, however, revealed a normal aortic valve and showed the presence of a large pedunculated mass in the left ventricular cavity, attached to the mid-portion of the interventricular septum and extending into the left ventricular outflow tract (LVOT), up to the aortic valve (Fig. 1).The left ventricular function was normal. On color flow there was mild

aortic regurgitation (grade I) with no significant gradient across the LVOT. Biplane transesophageal echocardiography (TEE) using a Hewlett Packard 5-MHz probe (Hewlett-Packard, Andover, MA, USA) was performed. The mass was an elongated pedunculated stnzcture, which was dumbell shaped and a good definition of the site of attachment to the mid-septum could be obtained. The length of the tumor was 6.2 cm and during systole the upper end extended into the LVOT, touching the cusps of the aortic valve (Fig. 2). There was mild aortic regurgitation and no significant outflow obstruction. Surgery was performed using cardiopulmonary bypass. A standard left atrial approach was adopted and the tumor exposed through the mi-

Figure l. Transthoracic echo showing a pedunculated left ventricular myxoma in parasternal long-axis (A) and apical four-chamber (B) views. Address for correspondence and reprints: Chander Vanjani, M.D., P.D.,Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai, India, 400 016. Fax:4451-515-4449151.

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GOEL, ET AL.

Figure 2. Preoperative transesophageal echocardiography (TEE) showing the relationship of the myxoma (shown by the arrow) to the aortic valve cusps.

tral valve. The attachment was to the septum behind the anterior mitral cusp, from which it was severed and completely removed. Postbypass TEE confirmed complete tumor removal (Fig. 31, an intact septum, and normal ventricular and aortic valve function. Subsequent histopathological examination confirmed the tumor to be a myxoma. The patient made a complete recovery and was discharged in good condition. Discussion After the first M-mode echocardiographic description of a left ventricular myxoma in 1977'

and its first two-dimensional (2-D) echo description in 1982,2 echocardiography has become a proven modality in the evaluation of this tumor. Although cardiac myxomas are the most common type of cardiac tumors, isolated myxomas of the leR ventricle are relatively rare. Occasionally they are discovered incidentally by echocardi~graphy.~ However, the utility of TEE in evaluating the left ventricular myxoma has not been adequately emphasized. In the case presented, complete morphological details and extent of the tumor could be given to the cardiac surgeon by the preoperative TEE examination. The excursion of the mobile pedunculated mass into the LVOT and exact relationship to the cusps of the aortic valve, were better documented by TEE than by the transthoracic examination. The complete removal of the tumor was well documented by the postbypass TEE. Thus, this case report highlights the utility of TEE in the evaluation and treatment of left ventricular myxoma.

References 1. Miller J, Teichholz LE, Pichard AD, et al: Left ven-

Figure 3. Postoperative transesophageal echocardiography (TEE)showing complete removal of the tumor from the left ventricle.

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tricular myxoma, echocardiographic diagnosis and review of literature. Am J Med 1977;63:816-823. 2. Mazer MS, Harrigan PR: Left ventricular myxoma-M mode and two dimensional echocardiographic features. Am Heart J 1982;104:875-877. 3. Wrisley D, Rosenberg J, Giambartolomei A: Left ventricular myxoma discovered incidentally by echocardiography. Am Heart J 1991;121:15541555.

ECHOCARDIOGRAPHY: A Jrnl. of CV Ultrasound & Allied Tech.

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