Asian Cardiovasc Thorac Ann 2000;8:64-66
© 2000 Asia Publishing EXchange Pte Ltd
Mitral Valve Myxoma
Senol Yavuz, MD,
Adnan Celkan, MD,
Yusuf Ata, MD,
Mustafa Mavi, MD,
Tamer Türk, MD,
Cüneyt Eris, MD,
Ayhan Özdemir, MD
Department of Cardiovascular Surgery
Bursa Yüksek htisas Hospital
Bursa, Turkey
|
|
For reprint information contact: Senol Yavuz, MD Tel: 90 224 360 5055 Fax: 90 224 360 2928 Department of Cardiovascular Surgery, Bursa Yüksek htisas Hospital, Duaçinari, Bursa 16330, Turkey.
|
 |
Abstract
|
|---|
A 65-year-old man had a 6 x 4 x 4 cm myxoma adhering to the posterior leaflet of the mitral valve. He underwent successful myxoma resection and mitral valve replacement.
|
Introduction
|
|---|
Myxomas are the most common tumors of the heart. They occur most frequently in the left atrium, arising from the fossa ovalis. Myxomas originating from the mitral valve are extremely rare. A case is described of a large myxoma arising from the posterior leaflet of the mitral valve, which was treated by surgical resection.
|
Case Report
|
|---|
A 65-year-old man who had exertional dyspnea and palpitations for several months, presented with acute pulmonary edema. He had no history of smoking, hypercholesterolemia, or familial myxoma. On physical examination, he was found to have a grade 4/6 systolic murmur and a 2/6 mid-diastolic murmur at the apex, respiratory distress, and basal inspiratory rales. His pulse was 115 beats•min–1 and regular. Blood pressure was 165/95 mm Hg. The lungs appeared to be wet on a chest radiograph. Electrocardiography indicated normal sinus rhythm. Symptoms were relieved by intensive diuretic treatment. Laboratory analysis showed an elevated erythrocyte sedimentation rate and a raised gamma-globulin level. Two-dimensional transthoracic echo-cardiography revealed a 5.2 x 3.5 cm mobile hetero-geneous discrete mass within the left atrium (Figure 1
). The mass was attached to the posterior leaflet of the mitral valve and appeared to be moving between the left atrium and the left ventricle. Significant mitral regur-gitation was observed. Other cardiac structures were normal. At catheterization, the coronary arterial system was normal but during ventricular diastole, the mass prolapsed through the mitral valve into the left ventricle (Figures 2 and 3). There was a right atrial pressure of 8 mm Hg, right ventricular pressure of 89/4 mm Hg, mean pulmonary artery pressure of 42 mm Hg, and pulmonary capillary wedge pressure of 27 mm Hg.
View larger version (139K):
[in this window]
[in a new window]
|
Figure 2. Ventriculogram in diastole demonstrating that the mass (filling defect) prolapsing into the left ventricle.
|
|
View larger version (139K):
[in this window]
[in a new window]
|
Figure 3. Ventricular cineangiogram in systole demonstrating a large filling defect in the left atrium.
|
|
For excision of the myxoma, the cavae were separately cannulated and snared. Cardiopulmonary bypass was instituted with moderate hypothermia and topical cooling. Through a left atriotomy, a large short-pedunculated mass was found firmly attached to the atrial surface of the posterior leaflet of the mitral valve (Figure 4). The tumor was solid and encapsulated, measuring 6 x 4 x 4 cm. After excision of the myxoma, the defect in the posterior mitral leaflet was inappropriate for valve repair; both leaflets were of a myxoid structure. The mitral valve was replaced with a 31-mm Carpentier-Edwards bioprosthesis (Baxter Healthcare Corp., Irvine, CA, USA). On inspection of the right atrium, right ventricular cavity, and tricuspid valve via a small right atriotomy, no abnormality was seen.
Histopathology of the resected specimen confirmed myxoma. Myxoid degeneration was noted on the excised leaflets of the mitral valve. The patient's postoperative course was uneventful and he was discharged on the 8th postoperative day. Postoperative echocardiography re-vealed a normally functioning mitral valve bioprosthesis and no residual mass. The patient was doing well 3 months after the operation.
|
Discussion
|
|---|
Mitral valve myxoma usually presents with the same features as left atrial myxoma.1 When the mitral valve is involved, the myxoma is frequently located on the atrial side with equal distribution between the anterior and the posterior leaflets.1–5 Such tumors may restrict valve opening, causing functional mitral stenosis. In this patient, the tumor led to annular dilation and destruction of the valve, resulting in mitral insufficiency.
Diagnosis of valve myxoma is usually made by twodimensional echocardiography. However, transesophageal echocardiography provides accurate identification of the tumor in respect of size, exact location, morphological characteristics, and point of attachment.5 This diagnostic tool also allows preoperative planning of the optimal therapeutic approach, such as valve repair or valve replacement.3 Before echocardiography, diagnoses of valve tumors were made incidentally at autopsy. The finding of a left atrial mass that completely prolapsed into the left ventricle during diastole and returned to the left atrium during systole suggested the valvular origin of the tumor.
Myxomas present with symptoms of hemodynamic obstruction, embolization, or constitutional manifestations. Although generally benign, they may lead to death due to obstruction or embolization within a few years after the onset of symptoms. Mitral valve tumors are more likely than aortic valve tumors to produce serious neurological symptoms or sudden death. Puff and colleagues6 reported sudden death in two cases of mitral valve myxoma. Progressive or acute mitral valve dysfunction can occur; in this case, the patient had acute pulmonary edema. Edwards and colleagues7 documented 56 cardiac valve tumors in 53 patients over a 58-year period. Each of the four valves was affected with approximately equal frequency. The most common histological type was papillary fibroelastoma (77.3%), followed by myxoma (9.4%). Chakfe and colleagues3 listed 21 cases of myxoma of the mitral valve and reported that embolization was the most common complication. Tumors ranged from 3 mm to 7 cm, with a mean diameter of 1.15 cm.3,6
All mitral valve myxomas require surgical resection because of their potential to obstruct the valve orifice, dilate the annulus, embolize, or cause rhythm disturbances. The preferred surgical technique is excision without valve resection if possible. Resultant varying degrees of mitral valve insufficiency can be treated by primary or patch repair of the valve or replacement with a prosthesis. Myxomas should be completely resected to avoid re-currence. A recurrence rate of 2% to 3% has been estimated.8 Recurrences are usually managed by re-excision. Inadequate primary excision, tumor seeding at the time of operation, and multiple foci of the tumor have been suggested as causes of recurrence. Because of possible recurrence, echocardiographic screening should be carried out at follow-up.
|
References
|
|---|
-
Sandrasagra FA, Oliver WA, English TAH. Myxoma of the mitral valve. Br Heart J 1979;42:221–3.[Abstract/Free Full Text]
-
Murphy DP, Glazier DB, Krause TJ. Mitral valve myxoma. Ann Thorac Surg 1997;64:1169–70.[Abstract/Free Full Text]
-
Chakfe N, Kretz JG, Valentin P, Geny B, Petit H, Popescu S, et al. Clinical presentation and treatment options for mitral valve myxoma. Ann Thorac Surg 1997;64:872–7.[Abstract/Free Full Text]
-
Kulshrestha P, Rousou JA, Tighe DA. Mitral valve myxoma: a case report and brief review of the literature. J Heart Valve Dis 1995;4:196–8.[Medline]
-
Zamorano J, Vilacosta I, Almeria C, San Roman A, Alfonso F, Sanchez-Harguindey L. Diagnosis of mitral myxoma by transesophageal echocardiography. Eur Heart J 1993; 14:862–3.[Abstract/Free Full Text]
-
Puff M, Taff ML, Spitz WU, Eckert WG. Syncope and sudden death caused by mitral valve myxomas. Am J Forensic Med Pathol 1986;7:84–6.[Medline]
-
Edwards FH, Hale D, Cohen A, Thompson L, Pezzella AT, Virmani R. Primary cardiac valve tumors. Ann Thorac Surg 1991;52:1127–31.[Abstract]
-
Shinfeld A, Katsumata T, Westaby S. Recurrent cardiac myxoma: seeding or multifocal disease. Ann Thorac Surg 1998;66:285–8.[Abstract/Free Full Text]
TOP
Abstract
Introduction
