“Tumor Vascularity” in Left Atrial Myxoma Demonstrated by Selective Coronary Arteriography

Abstract

Atrial myxoma is the commonest of the rare primary heart tumors and one of the few which is curable. Increasing interest in these lesions culminated in a recent symposium on cardiac tumors (8, 9, 14), in which the available literature was summarized in detail. The purpose of this communication is to show previously unreported “tumor vascularity” demonstrated by selective coronary arteriography in a proved case of left atrial myxoma. Case Report A 51-year-old Caucasian male presented with an eight-year history of intermittent dyspnea, orthopnea, ankle edema, and a recent weight gain of 15 lb. Between episodes of failure he was virtually asymptomatic. There was a questionable history of joint symptoms at the age of twelve years, and mild diabetes had been discovered two years previously. Pertinent negative findings included the absence of fever, anemia, or embolic phenomena. Physical examination showed moderate cardiac failure and an apical systolic murmur. The murmur did not alter dramatically with change in position. Laboratory data included: hematocrit 40 per cent, hemoglobin 13.5 g/100 ml, and gammaglobulin 1.1 mg/100 ml (normal for our laboratory). The erythrocyte sedimentation rate was 35 mm/hr. The electrocardiogram showed paroxysmal atrial tachycardia, thought to be related to digitalis intoxication or coronary insufficiency. Digitalis intoxication was excluded by an ouabain tolerance test, and the clinical impression was mitral valve disease or atrial septal defect with possible atherosclerotic heart disease. On Oct. 28, 1968, right and left heart catheterization showed low cardiac output, marked pulmonary hypertension, and wedge pressures, suggesting combined mitral valvular disease, predominantly insufficiency. Subsequently, selective angiography of the coronary arteries and retrograde left ventricular angiography showed only minor mitral insufficiency with apparent streamlining of contrast material in the left atrium. Because of this discrepancy, the patient was recatheterized. Transseptal left atrial and simultaneous left ventricular pressures showed a significant gradient across the mitral valve throughout diastole, suggesting that stenosis was the more dominant lesion. Echocardiography revealed normal mitral valve motion anterior to an area of inhomogeneous sound reflections (13). This was interpreted as indicating left atrial tumor. At surgery, a 7-cm myxomatous tumor was found in the left atrium attached to the lower atrial septum near the fossa ovale. The tumor impinged upon the mitral valve. Focal areas of calcification in its inferior portion were demonstrated by radiography of the surgical specimen. The posterior leaflet of the mitral valve was cleft and calcified; the anterior leaflet was normal. The tumor was removed and the cleft leaflet repaired. The postoperative course was satisfactory.