Asian Annals
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Lokeswara Rao Sajja
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Sajja, L. R.
Right arrow Articles by Rajasekhar, A.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Sajja, L. R.
Right arrow Articles by Rajasekhar, A.
Related Collections
Right arrow Cardiac - other
Asian Cardiovasc Thorac Ann 2001;9:322-324
© 2001 Asia Publishing EXchange Pte Ltd

CASE STUDY

Right Atrial Myxoma Arising from Crista Terminalis in Septuagenarian

Lokeswara Rao Sajja, MCh, Gopi Chand Mannam, FRCS, Krishnam Raju Penumatcha, DM1, Sriramulu Sompalli, MD2, Rajasekhar Angajala, MD3

Division of Cardiothoracic Surgery
1 Division of Cardiology
2 Division of Cardiac Anesthesiology
3 Division of Pathology Medwin Hospital Hyderabad, Andhra Pradesh, India
For reprint information contact: Gopi Chand Mannam, FRCS Tel: 91 40 666 1935 Fax: 91 40 662 5003 email: gmannam{at}yahoo.com Department of Cardiothoracic Surgery, CARE Hospital, Road No. 1, Banjara Hills, Hyderabad, Andhra Pradesh 500034, India.

   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 
A right atrial myxoma arising from the crista terminalis was detected during follow-up echocardiography in a 74-year-old man who had undergone coronary artery bypass grafting one year earlier. The myxoma was excised en bloc with a wide cuff of normal atrial wall and the right atrium was reconstructed with autologous pericardium.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
CASE REPORT
 DISCUSSION
 REFERENCES
 
Nearly half of the benign tumors of the heart are myxomas and they usually develop in the atria, with up to 75% in the left atrium. Most myxomas arise from the interatrial septum at the border of the fossa ovalis, but they can also originate (in descending order of frequency) from the posterior atrial wall, anterior atrial wall, and the appendage.1,2 Single cases of atrial myxomas arising from the tricuspid and eustachian valves have also been reported.3,4 A cardiac myxoma usually presents as a benign pedunculated tumor. Myxomas arising from the free wall of the atria may be asymptomatic until they become large and need to be resected because of their potential to embolize. A case of right atrial myxoma arising from an unusual and hitherto unreported location in a post-coronary artery bypass patient is described.


   CASE REPORT
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
DISCUSSION
 REFERENCES
 
A 74-year-old man who had undergone coronary artery bypass grafting one year previously was found to have an unusual shadow in the right atrium on a routine follow-up transthoracic echocardiogram. A transesophageal echo-cardiogram to assess this shadow showed a pedunculated mass arising from the anterior free wall of the right atrium. He was started on oral anticoagulants with a provisional diagnosis of right atrial thrombus or myxoma, and followed up as an outpatient. A repeat echocardiogram after 1 month of anticoagulant therapy showed that the mass had increased in size and the echogenic texture of the mass was suggestive of a myxoma. Physical exami-nation revealed a regular pulse of 76 beats•min-1, blood pressure of 130/80 mm Hg, and a respiratory rate of 16 breaths•min-1. On auscultation, the cardiovascular system was unremarkable and the lungs were clear. The cardiothoracic ratio, pulmonary parenchyma, and cardiophrenic angles were normal on chest radiography. An electrocardiogram showed sinus rhythm and no evidence of myocardial ischemia. The erythrocyte sedimentation rate was mildly elevated (27 mm in the first hour), and the total white cell count was 7,600/mm3. Total serum protein was 65 g•L-1 with a globulin level of 29 g•L-1. Two-dimensional transesophageal echo-cardiography revealed a 2 x 2-cm pedunculated mass within the right atrium, attached to the anterior free wall (Figure 1Go). There was no mass lesion seen in any other cardiac chambers. The tricuspid valve and other cardiac structures were normal. Selective left internal mammary artery injection showed occlusion of the graft. Coronary arteriography demonstrated a normal left anterior descending artery, and aortic root injection showed 2 patent saphenous vein grafts. The moderate stenosis (50%) of the left anterior descending artery, which had been present at the time of coronary artery bypass grafting, had regressed completely. Left coronary artery injection showed tumor blush in the region of the right atrium (Figure 2Go).



View larger version (88K):
[in this window]
[in a new window]
  		Figure 1. Transesophageal echocardiography in 4-chamber view showing a mass attached to the roof of the right atrium. LA = left atrium, RA = right atrium, RV = right ventricle.

 


View larger version (135K):
[in this window]
[in a new window]
  		Figure 2. Arteriogram of the left coronary artery in left anterior oblique view showing tumor blush in the region of the right atrium. LAD = left anterior descending artery.

 
The heart was exposed through a repeat median sternotomy and cardiopulmonary bypass was instituted in the standard fashion using 2 separate venous cannulae and an aortic cannula for arterial return. The patient was cooled to 32°C, and the right atrium was opened through an incision 1 cm parallel to the atrioventricular groove after tightening the loops around the superior and inferior venae cavae while the heart was beating. The tumor was attached to the crista terminalis and it measured 2 x 2 x 2 cm. It was excised en bloc with a wide cuff of normal atrial wall at its attachment, and the resultant defect was repaired with a patch of autologous pericardium. Histology of the resected specimen showed myxoid matrix and polygonal cells with scant eosinophilic cytoplasm scattered through-out the matrix. Occasional foci of ossification were also seen (Figure 3Go). The patient had an uneventful postoperative recovery and was discharged after 1 week.



View larger version (147K):
[in this window]
[in a new window]
  		Figure 3. Photomicrograph of the tumor showing myxomatous stroma (right half) and foci of ossification (left half). Hematoxylin and eosin stain, original magnification x200.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
REFERENCES
 
The clinical features of myxomas are determined by their location, size, and mobility. Most patients present with one or more of the triad of embolism, intracardiac obstruction, and constitutional symptoms.5 Occasionally, there are no symptoms, particularly with small tumors. In cases of right atrial myxoma, clinically evident embolic events are uncommon. Nevertheless, there have been reports not only of embolization of thrombi or tumor fragments into the pulmonary arteries with subsequent pulmonary hypertension, but also of lethal fulminant pulmonary embolism in cases of right atrial or right ventricular myxoma.6 Calcification with occasional foci of metaplastic bone have been observed in approximately 10% of cases and it is more common with right atrial masses. Echocardiography, computed tomography, and magnetic resonance imaging are important noninvasive diagnostic tools. The diagnosis of myxoma is usually made by two-dimensional echocardiography, and trans-esophageal echocardiography provides accurate infor-mation in respect of size, exact location, morphological characteristics, and the point of attachment. A myxoma arising from the right atrial free wall requires surgical excision because of its potential to produce acute massive pulmonary embolism or chronic multiple small emboli leading to pulmonary hypertension, or obstruction of the tricuspid valve or venae cavae if it enlarges. Myxomas must be excised completely along with their attachments to avoid recurrence.

In this patient, the myxoma was small and arose from the anterior wall near the crista terminalis. It was not detected one year earlier when he was evaluated by echo-cardiography prior to myocardial revascularization. Histologically, the foci of ossification seen in the resected specimen is not an unusual finding in myxomas of the right side. Another interesting feature of this patient was total regression of the atherosclerotic lesion in the left anterior descending coronary artery, which was evident on the repeat coronary angiogram. The regression of atherosclerosis was probably due to cholesterol-lowering therapy with statin. The internal mammary artery graft might have been occluded because of competitive flow between this graft and the native left anterior descending artery.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 

  1. McAllister HA Jr, Fenoglio JJ Jr. Tumors of the cardiovascular system. In: Atlas of tumor pathology. 2nd series. Fascicle 15. Washington DC: Armed Forces Institute of Pathology, 1978:1–20.

  2. Reynen K. Cardiac myxomas. N Engl J Med 1995; 333:1610–7.[Free Full Text]

  3. Kuroda H, Nitta K, Ashida Y, Hara Y, Ishiguro S, Mori T. Right atrial myxoma originating from the tricuspid valve. J Thorac Cardiovasc Surg 1995;109:1249–50.

  4. Teoh KH, Mulji A, Tomlinson CW, Lobo FV. Right atrial myxoma originating from the eustachian valve. Can J Cardiol 1993;9:441–3.[Medline]

  5. Wold LE, Lie JT. Cardiac myxoma. A clinicopathological profile. Am J Pathol 1980;101:219–40.[Medline]

  6. Aru GM, Cattolica FS, Cardu G, Meloni L, Catani G, Martelli V. A fractured and detached right atrial myxoma: an unusual and threatening condition detected by intra-operative transesophageal echocardiography. J Thorac Cardiovasc Surg 1992;104:215–7.[Medline]





This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Lokeswara Rao Sajja
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Sajja, L. R.
Right arrow Articles by Rajasekhar, A.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Sajja, L. R.
Right arrow Articles by Rajasekhar, A.
Related Collections
Right arrow Cardiac - other

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS