1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; 2Universitätsklinikum Hamburg-Eppendorf II. Medizinische Klinik und Poliklinik (Onkologie, Hämatologie, Knochenmartransplantation mit Abteilung für Pneumologie) Hamburg, Deutschland; 3Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; 4Universitätsklinikum Hamburg-Eppendorf Hamburg, Deutschland; 5Universitätsklinikum Hamburg-Eppendorf Klinik für Radiologie Hamburg, Deutschland
Background:
Cardiac myxomas (CM) are the most prevalent benign cardiac tumors. They are frequently asymptomatic but potentially cause heart failure and thromboembolic events, including stroke, yet there is no standardized diagnostic pathway. In this study, the value of preoperative transthoracic (TTE) and transoesophageal echocardiography (TEE) was evaluated.
Methods:
In this retrospective single-center study, we analyzed a cohort of adult patients presenting with clinically suspected CM to a tertiary referral center between 2012 and 2023. Clinical data were collected from the patients´ electronic medical records. Two independent investigators compared TTE and TEE images for echogenicity, location, insertion site, size, and myxoma homogeneity.
Results:
A total of 39 patients (median age 61 years, 77% women) was analyzed. Interestingly, one-third of the cases were incidentally discovered (33.3%), e.g. during routine check-ups (n=4), computed tomography (CT) for other indications (n=3), or perioperative cardiovascular imaging (n=2). Among symptomatic patients, dyspnea was the predominant complaint (26.6%), with 13% reporting symptoms such as dizziness, pre-syncope, or syncope. Three patients presented with stroke, and one had an epileptic seizure. Initial diagnoses were primarily made through TTE, with four cases incidentally discovered by CT.
The size of CMs varied, with 69% measuring 4 cm or less. The majority were located in the left atrium (87.2%), followed by the right atrium, anterior mitral leaflet, and posterior mitral leaflet.
TTE was the sole diagnostic tool in 25.6% of cases. The most common additional imaging method was TEE (n=23), followed by CT (n=14) and CMR (n=9). Notably, CT was used either for preoperative diagnostics (n=8) or for other indications (n=6). Before resection, 94.3% of patients received invasive coronary angiography (ICA). Interestingly, TEE did not provide superior insights regarding tumor size as compared to TTE, while CMR was most reliable for determining the insertion point (Table 1). Grading of valve regurgitation and stenosis showed 88.8% congruence in TTE and TEE. CMR was typically employed when there was already a high clinical suspicion based on prior TTE examinations.
Out of the total CM cases, 89.7% were surgically resected, and 11 patients underwent concomitant procedures. The most common procedure was valve repair (n=5), followed by coronary artery bypass (n=3), patent foramen ovale closure (n=2), and valve replacement (n=1). Postoperative complications (n=8, 22.9%) included stroke (n=1), hemorrhagic shock (n=1), bradyarrhythmia requiring pacemaker implantation (n=2), pneumonia (n=2), neuropathic pain (n=1), and postcardiotomy syndrome (n=1). The average hospital stay was 11.2 days, and all patients were discharged alive.
Conclusion:
In this single-center series, most CMs were detected using TTE. Clinical characteristics of the patients (mainly women, 61 years median age) and perioperative outcome are in line with expectations. Surgical resection and cardiac repair were performed after ICA in nearly all cases (89.7%). Notably, TEE did not offer clinically relevant additional information regarding size or insertion point of CM as compared to TTE in this cohort.
Table 1: Comparison of diagnostic methods
|
Parameter |
TTE |
TEE |
CMR |
|
Average deviation from longest diameter as compared to pathological derived measures |
21% |
35% |
12% |
|
Determination of insertion point |
80.0% (20/25) |
84.6% (11/13) |
100% (6/6) |