Cardiac myxoma is a well-known primary cardiac tumor usually located in the left atrium [1]. Cardiac myxomas most commonly appear on echocardiography as a pedunculated tumor attached to the interatrial septum, with a smooth outline that does not disturb bordering structures [2, 3]. We present a unique case of a myxoma with an extremely irregular and branching structure and highly vascular phenotype that gave it the appearance of a lit Christmas tree on echocardiography.
A 55-year-old woman was admitted to the hospital after two consecutive episodes of transient ischemic attacks (TIA) that occurred within 36 hours before admission. Her past medical history did not include any previous complaints or diseases, nor did she have a significant family history. Physical examination, laboratory tests, and electrocardiography were normal. Transthoracic echocardiography showed a large, extremely mobile mass in the left atrium (Figure 1A, B).
Transesophageal echocardiography (TEE) further demonstrated irregular branching morphology of this tumor (Figure 1C, D). Color Doppler recorded with a low flow velocity scale showed multiple color dots indicating significant tumor vascularity. It gave the tumor the appearance of a colorfully lit Christmas tree moving in the wind (Supplementary materials, Videos S1, S2). Urgent coronary angiography excluded coronary artery disease but showed a pathological branch of the right coronary artery (RCA) vascularizing the mass in the left atrium (Figure 1E). The Heart Team decided to perform urgent surgical resection of the tumor. A gelatinous, extremely fragile, pedunculated, and easily fragmentable mass was excised during cardiac surgery (Figure 1F). Subsequent histopathology confirmed that it was a cardiac myxoma with no signs of malignancy. Five-year follow-up was uneventful, and the patient did not report any recurrent symptoms.
Typically, cardiac myxomas have smooth surfaces and pedunculated structures. The current case shows an extremely fragile and mobile subtype associated with multiple TIA episodes. Urgent echocardiography, including TEE and low-velocity color Doppler imaging, was able to fully characterize the mass and detect multiple small vessels, whose presence was then confirmed by coronary angiography and histopathological exam. Extensive vascularization often suggests a malignant nature of the tumor due to abnormal neovascularization and demonstrates greater enhancement than the adjacent myocardium, but as documented here, it may also exist in benign tumors [5]. The irregular fragile structure of this myxoma was associated with two recent TIA episodes in an otherwise healthy patient with no cardiovascular risk factors. The case shows that prompt diagnostic workup is essential in patients with TIA. Myxomas should be excised without delay, however, excision should be performed with the highest urgency in irregular tumors that have already led to embolic complications [1, 4]. Evidence of tumor vascularization may also lead to alterations in the resection strategy.
Supplementary material
Supplementary material is available at https://journals.viamedica.pl/kardiologia_polska.
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