The value of coronary angiography in the work-up of atrial myxomas

Case report: Left atrial myxoma with morphology of cavernous hemangioma supplied by the right coronary artery

Here, we report an unusual case of left atrial myxoma presented with morphology of cavernous hemangioma supplied by the right coronary artery. Surgical resection of the left atrium myxoma was performed, and the patient experienced an uneventful recovery during hospitalization.

Left atrial myxoma: an unusual cause of pre-syncope and symptomatic bradycardia

BACKGROUND

Atrial myxomas account for approximately 50% of all primary cardiac tumors. The size, location, risk of embolic event, and involvement of other cardiac structures, are all factors that contribute to the wide range of presentation for cardiac myxomas. Patients with myxomas may remain asymptomatic, while others may report symptoms such as fatigue and fever, dyspnea, and syncope. It is important to recognize arrhythmias as an uncommon symptom of myxomas.

CASE PRESENTATION

We report a rare case of a 67-year-old man who presented with pre-syncopal episodes, symptomatic bradycardia, and night sweats found to have a 5.5 × 5.1 × 3 cm myxoma in the left atrium. During diastole the mass caused dynamic flow obstruction across the mitral valve. The patient underwent surgical resection of the mass given his symptomatology and risk of embolic events. Removal of the myxoma resulted in resolution of both pre-syncopal episodes and the patient's sinus bradycardia.

CONCLUSION

Atrial myxomas are a rare cause of pre-syncope and symptomatic bradycardia. It is important to have a clinical suspicion for atrial myxomas given early diagnosis and surgical intervention are key in improving the prognosis of these patients. This case also highlights the importance of taking into account the source of the myxoma's blood supply in relationship to other cardiac structures, and further correlating these findings with clinical symptoms.

Clinical Significance of Angiographically Detectable Neovascularity in Patients with Cardiac Myxoma

Background: Myxomas are the most common primary cardiac tumors. Angiographically detectable neovascularity (ADN) of myxoma is increasingly being reported as a result of the use of coronary angiography (CAG) to detect coronary artery disease. However, the clinical significance of these findings is not fully understood.Methods: We enrolled 59 patients with cardiac myxoma who also underwent CAG between January 2013 and October 2018. Patients were followed up for a mean of 28.9 months (range 1‐69 months). The clinical features, echocardiography measurements, pathological examination findings, CAG results, and outcomes during follow-up were compared between patients with ADN and patients without ADN.Results: ADN was found in 25 patients (42.4%). The arteries feeding the ADN included the right coronary artery (n=15), the left circumflex coronary artery (n=7), and both arteries (n=3). The patients with ADN had a higher proportion of eosinophils (3.2% vs. 2.2%, P=0.03) and higher low-density lipoprotein cholesterol level (2.7 mmol/L vs. 2.2 mmol/L, P=0.02). Myxoma pedicles were more likely to be located in the interatrial septum in patients with ADN (96% vs. 73.5%, P=0.02). No significant correlation was observed between the groups in clinical manifestations, atrial arrhythmia, myxoma size, cardiac chamber size, left ventricular ejection fraction, and the prevalence of complication with coronary artery disease [16% in the ADN group (n=4) vs. 20.6% in the non-ADN group (n=7), P=0.66]. However, patients with ADN tended to have a lower incidence of major adverse cardiac and cerebrovascular events on long-term follow-up (0% vs. 14.7%, P=0.07).Conclusion: CAG-detected ADN in patients with cardiac myxoma is associated with a borderline lower rate of major adverse cardiac and cerebrovascular events.

Right Atrial Myxoma with Coexistent Coronary Artery Disease - A Rare Combination

Atrial myxomas are the most common primary heart tumors. Two-dimensional echocardiography is the diagnostic procedure of choice. The majority of myxomas are located in the left atrium. Myxoma in the right atrium is an uncommon location. The co-occurrence of right atrial myxoma with atherosclerotic coronary artery disease (CAD) is uncommon. In our case, right atrial myxoma was associated with CAD, which makes it a unique case because very few cases of right atrial myxoma coexistent with CAD are described in literature.

A Giant Right Atrial Myxoma with Blood Supply from the Left and Right Coronary Arteries: Once in a Blue Moon

Cardiac myxomas, the commonest primary benign cardiac tumors, are extremely rare, with an incidence ranging from 0.0017 to 0.19% and only about one-fifth of them originating from the right chambers of the heart. A 60-year-old woman was admitted because of recurrent attacks of chest tightness and shortness of breath. Transthoracic echocardiography detected a giant mass in the right atrium; myxoma was indicated by [18F]fluorodeoxyglucose PET/CT. Preoperative selective coronary angiography was performed to assess the extent and severity of coronary stenosis, and showed a strongly neovascularized right atrial mass supplied by two feeding vessels with multiple branches from the left and right coronary arteries. The myxoma was successfully excised with open heart surgery and the patient was free of myxoma recurrence during the 3-year follow-up.

Value of Coronary Angiography in the Cardiac Myxoma

Preoperative coronary angiography for cardiac myxoma not only excludes coronary artery disease but also detects the artery feeding the cardiac myxoma, which has several clinical implications. In this study, we examined cardiac myxoma cases in two tertiary hospitals using coronary angiography to identify the artery feeding the myxoma. We retrospectively reviewed 42 patients with cardiac myxoma who had undergone surgical removal between July 2008 and December 2015 in two tertiary hospitals, and recorded their baseline characteristics, echocardiographic findings, and coronary angiography. Among those 42 patients, 23 (55%) had coronary angiography before surgery and in no case was significant luminal narrowing observed. In 21 of the coronary angiograms, the artery feeding the cardiac myxoma had a vascular branch (100%), clusters of tortuous vessels with contrast medium pooling (67%), an arteriocavity fistula (33%), and a mobile feeding artery (67%). No significant relationship was found between coronary artery dominance type and the origin of the artery feeding the cardiac myxoma (P = 0.362). Identification of the artery feeding the cardiac myxoma, with a distinctive vascular appearance in coronary angiography, is important for several clinical applications such as helping to diagnose cardiac myxoma and to plan the surgical approach. Clin. Anat. 33:833-838, 2020. © 2019 Wiley Periodicals, Inc.

The importance of mass diameter in decision-making for preoperative coronary angiography in myxoma patients

OBJECTIVES

Although coronary angiography (CAG) is generally performed to rule out coexisting coronary artery disease in patients with cardiac myxoma, its necessity to evaluate vascular supply of the myxoma is debatable. The aim of this article is to evaluate clinical experience and CAG findings in our patient group.

METHODS

This retrospective analysis was performed in 46 patients (17 men, mean age 57.7 ± 8.6 years), who underwent surgery with an indication for cardiac myxoma between 2004 and 2016 with a CAG performed preoperatively. All CAGs were evaluated in a blinded manner by a cardiac surgeon and a cardiologist separately. Correlations between the presence and pattern of feeding vessels, presence of an arteriocavity fistula (ACF), coronary arterial dominance, size of mass and clinical presentations were analysed.

RESULTS

Coronary artery disease defined as >50% obstructive lesions was detected in 10 patients (21.7%). The tumour diameter was found to be significantly higher in patients who had an ACF and a dual-feeding artery (P = 0.049 and P = 0.0001, respectively). Additionally, there was a significant relationship between the presence of dual-feeding vessels and ACF (P = 0.014). ROC analysis revealed a cut-off point of 27 mm in diameter based on the presence of an ACF and a dual-feeding artery. In cases with a diameter of 27 mm or above, the risk of existence of an ACF was 4.68-fold greater, with a confidence interval of 95%, and a dual-feeding pattern was seen in all of them.

CONCLUSIONS

This study suggests that preoperative CAG can be considered to detect feeding vessels that may lead to a steal phenomenon, which may alter the management in patients with myxoma greater than 27 mm in diameter.

Multi-modality imaging of a left atrial myxoma

Objectives

Although echocardiography has traditionally been used to diagnose myxoma, invasive or non-invasive coronary angiography can be useful diagnostic tool before surgery.

Methods

We present a case of an angiographically detected left atrial myxoma feeding from the left circumflex coronary artery.

Results

The patient underwent open-heart surgery to remove the left atrial myxoma. After ligation of feeding artery, the mass was successfully excised.

Conclusion

Preoperative coronary angiography can offer additional valuable information moreover detecting coronary artery disease. Because, there is sudden death risk from embolization during invasive coronary angiography, preoperative cardiac computed tomography angiography should be considered to plan the surgery of myxoma.

Left Atrial Myxoma Hypervascularized from the Right Coronary Artery: An Interesting Cath Lab Finding

Primary cardiac tumors are rare and approximately half of them are atrial myxomas. They rarely remain asymptomatic, especially if large. The imaging of a myxoma by contrast dye during coronary angiography is an infrequent sign, which clarifies the vascular supply of the tumor. We report herein an interesting and rare case of a left atrial myxoma hypervascularized from the right coronary artery.

A giant left atrial myxoma neovascularized from the right coronary artery

Myxomas are benign and the most common tumors of the cardiac muscle (Reynen, 1995). They are predominantly located in the left atrium. Clinical manifestations may vary according to the localization and the size of the myxoma. On the other hand, imaging of a myxoma by contrast dye during coronary angiography is a rare sign, which displays the vascular supply of the tumor. Here, we report the case of a 51-year-old man presenting with presyncope and palpitations due to a giant left atrial myxoma having its vascular supply from the right coronary artery (RCA).