Delineating thrombus versus myxoma: Perioperative 3D transesophageal echocardiography to the rescue!

Abstract

Cardiac masses are a significant cause of patient morbidity and mortality by virtue of their symptoms and surgical removal. Preoperative diagnosis of a cardiac mass is usually based on clinical correlation and transthoracic echocardiography findings. Myxomas are the most common benign cardiac tumors, commonly occurring in the left atrium attached to the interatrial septum near the fossa ovalis. Although, at times atypical location and unusual morphology may pose a diagnostic dilemma with 2D echocardiography. 3D echocardiography with its multifaceted advantages, including multiplanar cropping abilities and superior imaging quality can help distinguish between a clot and a myxoma.

Keywords: 3D echocardiography; Myxoma; Thrombus.

Figure 1:

19-year-old male presented with dyspnea on exertion over 2 years with abdominal distension and pedal edema for 12 months. (a) 2D transesophageal echocardiography (TEE) image in midesophageal 4 chamber right focused view (0°) shows a homogenous mass located on the supero-lateral wall of the right atrium (RA) measuring 3.5 cm × 3.8 cm with spontaneous echo contrast (blue arrow). (b) 2D TEE image in midesophageal bicaval view, showing the mass on the superolateral wall of a dilated right atrium (RA).

Figure 2:

A 19-year-old male presented with dyspnea on exertion over 2 years with abdominal distension and pedal edema for 12 months. (a) 3D transesophageal echocardiography (TEE) showing multi-planar reconstruction of the mass in the right atrium (RA). (b) 3D TEE view from the right ventricular aspect. The mass (hollow yellow arrow) on the superolateral surface of the RA has a granular surface with the presence of red colored, cross-shaped (blue arrow) artifacts due to spontaneous echo contrast.

Figure 3:

A 19-year-old male presented with dyspnea on exertion over 2 years with abdominal distension and pedal edema for 12 months. 3D transesophageal echocardiography images using tissue rendering mode: (a) mass viewed from the left atrium with the interatrial septum removed and the image flipped with the inferior portion on top shows areas of echolucency (black arrow) within the mass (hollow yellow arrow). (b) Mass viewed from the lateral wall of the right atrium, showing a rough echotexture (blue arrow). (c) shows a crop plane cutting through the middle of the mass, the random small areas of echolucency and few irregular calcifications (black arrow head) are suggestive of a tumor rather than a thrombus. Right atrium (RA).

Figure 4:

A 19-year-old male presented with dyspnea on exertion over 2 years with abdominal distension and pedal edema for 12 months. Mass after surgical excision is shown above.