Giant cardiac myxoma: Real time characterization by 64-slice Computed Tomography

A 70-year-old woman was admitted at our institution because of recent onset of palpitations, dyspnea, and fatigue. On physical examination, she appeared well and she did not present particular signs except for a pulse rate of 114 beats per minute; her blood pressure was 155/85 mm Hg, axillary temperature was 36.7°C, respirations were 16 breaths per minute, and arterial blood gas measurements were normal. The chemistry and hematologic laboratory values were within the normal reference ranges. Electrocardiography revealed sinus tachycardia at a rate of 115 beats per minute and diphasic P waves in leads II, aVF, and V3 through V5. A chest radiography showed no abnormalities of the heart and mediastinum, and the lungs were clear. However, in the lateral view, an egg-shaped image corresponding to the atria was present and appeared highly suspicious for an intracardiac mass. A transthoracic echocardiographic examination disclosed a dilated left atrium (60 × 40 mm) filled almost entirely by a mobile, pedunculated mass of echoes, 2.7 by 7 cm, that partially prolapsed into the left ventricle during diastole with an incomplete closure of the mitral valve leaflets and an associated jet of mild regurgitation (Figure 1). The mass was highly mobile and appeared to be attached to the interatrial septum by a large stalk (2 cm). Transesophageal echocardiogram was impracticable because of the presence of Zenker's diverticulum.A 64-slice contrast-enhanced computed tomography (LightSpeed VCT, GE Healthcare, Milwaukee, Wis) was performed to confirm the diagnosis. Multiplanar reconstructions exactly defined the tumor attachment in the angle between the upper portion of interatrial septum and the left atrial roof (Figure 1). Functional and dynamic features were obtained by 3-dimensionally rendered real-time reconstructions (Aquarius, Tera Recon, San Mateo, Calif) that demonstrated this huge mass prolapsing through the mitral orifice and greatly reducing the diastolic filling of the left ventricle (Video 1). The patient had an urgent operation. Because of the large dimensions and the site of implant, we preferred a biatrial approach; thus the resection was accomplished in a “septal superior approach fashion.” Actually, by direct visualization, the mass presented a large stalk localized in the upper interatrial septum and widely extending to the roof of the left atrium. The tumor was extracted en bloc, and gross inspection showed a huge trilobulated mass measuring about 4 × 7 × 3 cm with a stalk of 2 × 2 cm (Figure 2). Fresh section revealed a reddish mass with diffuse hemorrhagic infiltration strongly suggestive of cardiac myxoma. Once the mass had been removed, the mitral apparatus was carefully inspected for possible valve incompetence that was preoperatively undetectable. However, the saline solution injection revealed only a trivial central regurgitation not susceptible of surgical correction.The procedure was completed as usual without complications, and the postoperative course was uneventful except for the occurrence of a junctional rhythm, which spontaneously resolved in the third postoperative day. Histology confirmed the diagnosis of myxoma.