Myxoma echocardiography or ultrasound

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Maria Fernanda Villarreal, M.D. [2] Cafer Zorkun, M.D., Ph.D. [3]

Overview

On cardiac ultrasound, myxoma is characterized by the presence of a heterogeneous pedunculated mass that is commonly located in the left atrium. Cardiac myxomas appear as hyperechogenic lesions with a well-defined stalk. Moreover, echocardiography can be useful to evaluate the function identification and evaluation of cardiac myxomas in real-time imaging. As an imaging modality, two-dimensional echocardiography is often coupled with other testing modalities (such as, Doppler echocardiography) to detect vascular abnormalities that frequently occur in cardiac myxomas.

Echocardiography

The echocardiogram is the initial modality and most useful diagnostic imaging study in cardiac myxoma. Echocardiography allows for the accurate assessment of tumor mobility, as it often protrudes through valve flaps. As a test modality, two-dimensional echocardiography is often coupled with other modalities (such as, Doppler echocardiography and M-mode) to detect echogram alterations or flow abnormalities that frequently occur in cardiac myxomas.[1]

Transthoracic echocardiography

Transthoracic echocardiography (TTE) is the imaging method of choice in cardiac myxoma. This imaging study is noninvasive and characterizes heart morphology in a variety of imaging planes that can demonstrate tumor mobility and distensibility.[2] It also provides a large amount of functional information. Transthoracic echocardiography is mainly limited by the available imaging window, which mainly depends on operator experience.[3]

The echocardiographic findings in left cardiac myxoma include: [4]

  • The tumor prolapses into the left ventricle (LV) immediately after the opening of the mitral valve at the onset of diastole.
  • Tumor masses evoke bandlike echoes behind the anterior mitral leaflet.
  • There is a small echo-free gap behind the end-diastolic (DE) amplitude of the anterior mitral leaflet represents the short interval between the opening of the mitral valve and the protrusion of the tumor.

Transesophageal echocardiography

Transesophageal echocardiography (TEE) is an invasive imaging technique it may be helpful in the evaluation of extracardiac structures such as, the descending aorta and pulmonary veins. Unlike transthoracic echocardiography there is no limitation to the acoustic window, better image resolution is often reached. Findings on cardiac myxomas, such as compression of cardiac structures can be better identified by TEE. TEE can also be used to detect small vegetations and tumors (1 to 3 mm in diameter).[5][6]

Doppler echocardiography

A hallmark feature of Doppler echocardiography in cardiac myxoma is measuring velocity and chamber pressures, it may be helpful in the assessment of cardiac valve areas and function.[7] In some cases, this modality is coupled with contrast-enhanced ultrasound using gas-filled microbubble contrast media to improve velocity or other flow-related measurements.[8]

M-mode

M-mode echogram modality may be helpful to evaluate abnormal echoes within the atrial cavity. Because of spatial limitations, ultrasonic beam may fail to traverse the mass, particularly if the size is small or if the tumor remains within the atrial cavity.[9]

Echocardiography Examples of Cardiac Myxoma

Echocardiogram apical 4-chamber image view of atrial myxoma[10]
Imaging Technique Features Description Advantages Limitations
Two- or three-dimensional echocardiography
  • Echocardiography is usually the initial modality used for identification and evaluation of cardiac myxomas.
  • Hyperechogenic lesions with a well-defined stalk.
  • Protrusion into the ventricles is a common finding.
  • Real-time imaging
  • Tumor mobility and distensibility.
  • Limited views of the mediastinum and cannot be used to evaluate extracardiac manifestations of disease.[11]
  • TEE is an invasive imaging technique.
  • TT is limited by the imaging window, which can vary with the patient and operator experience.
MRI
  • Evaluation of cardiac masses and is of greatest value when echocardiographic findings are suboptimal or when the lesion has an atypical location or appearance.
  • Cardiac myxomas appear spherical or ovoid with lobular contours, irregular in shape.
  • T1 : Low to intermediate signal, but areas of hemorrhage may be high.
  • T1 C+ (Gd): shows enhancement (important discriminator from a thrombus) demonstrates uniform heterogeneous enhancement.
  • MRI allows imaging in multiple planes.
  • Provides some functional information such as, flow direction and flow velocity in large vessels.
  • Cannot show calcification.
  • High susceptibility to motion artifact.
  • Dependent on regular electrocardiographic rhythms and cardiac gating.
CT
  • CT can be used to accurately image the heart and surrounding mediastinum.
  • Intracardiac heterogeneously low attenuating mass.
  • The attenuation is usually lower than that of myocardium.
  • Calcification is common
  • CT provides better soft-tissue contrast.
  • There is no real-time true imaging with CT and imaging planes are limited to those allowed by angulation of the gantry.
  • There is no evaluation of small moving structures, such as the cardiac valves.
Angiography
  • Coronary angiography may be helpful to detect vascular supply of the tumor by the coronary arteries.
  • The angiographic findings of cardiac myxoma demonstrate feeding vessels, contrast medium poolings, and clusters of tortuous vessels that correspond to tumor vasculature
  • Angiography can detect the concomitant coronary disease and the unique vascular appearances of cardiac myxoma.
  • Helpful for surgical evaluation.
  • Invasive imaging technique
Chest x-ray
  • Chest x-ray has no particular findings associated with cardiac myxoma.
  • Results can be normal.
  • Low cost
  • May be helpful, if calcifications present.
  • Does not provide a diagnosis.

References

  1. Bentivoglio M, Savino K, Corea L, Verdecchia P, Porcellati C (1989). "[Doppler echocardiography in atrial myxoma]". Cardiologia (in Italian). 34 (9): 783–6. PMID 2605587.
  2. Mundinger A, Gruber HP, Dinkel E, Geibel A, Beck A, Wimmer B, Schlosser V (1992). "Imaging in cardiac mass lesions". Radiat Med. 10 (4): 135–40. PMID 1410560.
  3. Araoz PA, Eklund HE, Welch TJ, Breen JF (1999). "CT and MR imaging of primary cardiac malignancies". Radiographics. 19 (6): 1421–34. doi:10.1148/radiographics.19.6.g99no031421. PMID 10555666.
  4. Vopat RL, Alpert MA, Flaker GC, Curtis JJ, Webel RR, Sanfelippo JF (1986). "Limitations of echocardiography in the diagnosis of left atrial myxoma: a case report". Angiology. 37 (7): 547–51. PMID 3729078.
  5. Stern R (1996). "Cardiac myxomas". N. Engl. J. Med. 334 (21): 1408, author reply 1408–9. PMID 8614442.
  6. Engberding R, Daniel WG, Erbel R, Kasper W, Lestuzzi C, Curtius JM, Sutherland GR, Lambertz H, von Hehn A, Lesbre JP (1993). "Diagnosis of heart tumours by transoesophageal echocardiography: a multicentre study in 154 patients. European Cooperative Study Group". Eur. Heart J. 14 (9): 1223–8. PMID 8223737.
  7. Okuri H, Shimizu M, Yokoyama K, Kawada H, Irisawa A, Kikawada R (1993). "[A case of right atrial myxoma: M-mode and pulsed-Doppler echocardiographic findings before and after operation]". Kokyu To Junkan (in Japanese). 41 (4): 397–401. PMID 8516580.
  8. Doppler echocardiography.Wikipedia. https://en.wikipedia.org/wiki/Doppler_echocardiography Accessed on November 30, 2015
  9. Pechacek LW, Gonzalez-Camid F, Hall RJ, Garcia E, de Castro CM, Leachman RD, Montiel-Amoroso G (1986). "The echocardiographic spectrum of atrial myxoma: a ten-year experience". Tex Heart Inst J. 13 (2): 179–95. PMC 324624. PMID 15227359.
  10. Atrial Myxoma. Wikipedia.https://en.wikipedia.org/wiki/Atrial_myxoma Accessed November 25,2015 on
  11. Reeder GS, Khandheria BK, Seward JB, Tajik AJ (1991). "Transesophageal echocardiography and cardiac masses". Mayo Clin. Proc. 66 (11): 1101–9. PMID 1943240.

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