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Left atrial appendage mass: is it always a thrombus?
Hikmet Sahratov, Adem Guler, Mustafa Kurkluoglu, Fahri Gurkan Yesil, Murat Tavlasoglu, Faruk Cingoz
Kardiochirurgia i Torakochirurgia 2016; 13 (4): 359-360
- Left atrial appendage mass.pdf [0.20 MB]
IntroductionMyxomas are the most common benign tumors of the heart. Cardiac myxomas are found in the left atrium in 80–90% of cases and are often attached to the interatrial septum. Myxomas originating from the left atrial appendage are very rare. In this report, we present a patient in whom surgery was performed after the diagnosis of mitral valve stenosis, chronic atrial fibrillation, and a possible left atrial appendage (LAA) thrombus (which was incidentally diagnosed as a myxoma).
Case reportThe 50-year-old male patient was admitted for surgery with the diagnosis of mitral stenosis and chronic atrial fibrillation. Two-dimensional transthoracic echocardiography showed severe mitral valve insufficiency and reported spontaneous echo contrast which could signify the presence of a thrombus in the left atrium. Transesophageal echocardiography demonstrated a mass attached to the wall of the left atrial appendage. Surgery was performed via median sternotomy with cardiopulmonary bypass. The left atrium was explored after cardioplegic arrest; within, fragile areas containing white tissue mass and attached to the left atrial appendage were observed (Fig. 1). After the mass was removed, the LAA was plicated internally and excised externally. Mitral valve replacement was performed. The postoperative period was uneventful. Histopathological examination showed an image compatible with a myxoma containing myxomatous areas (Fig. 2).
DiscussionAtrial myxomas are encountered in 0.2% to 0.3% of the general population. Their most common symptom is exertional dyspnea, but they can also cause fever, weight loss, syncope, sudden death, and hemoptysis [1, 2]. A cardiac myxoma is usually attached to the left atrial side of the interatrial septum near the region of the fossa ovalis . However, in very rare cases, myxomas can originate from the LAA. It is very rare to see any mass other than a thrombus at the left atrial appendage, especially in patients with atrial fibrillation . The other factors that also led us to mistake the myxoma for a thrombus were the presence of atrial fibrillation and the underlying mitral stenosis.
On the echocardiogram, myxomas are typically seen as attached to the endocardium with a pedicle . If the location of the pedicle is not fully identified on echocardiography, it may be difficult to differentiate a left atrial myxoma from a thrombus . It is important to distinguish between thrombi and myxomas preoperatively, but it may sometimes be challenging . Myxomas are generally located within the body of the left atrium; they are bigger, pedunculated, and mobile. Thrombi are usually located in the left atrial appendage; they are immobile and have a wider base.
New imaging techniques, such as myocardial perfusion contrast echocardiography, are used to differentiate cardiac masses. Contrast echocardiography enables the analysis of the vascular pattern of the cardiac mass: benign tumors generally exhibit lower vascularity than malignant tumors, while thrombi are avascular .
Thrombi and myxomas originating in the LAA are not always easy to differentiate. If there are no constitutive symptoms such as fever, weight loss, arthralgia, or myalgia, distinguishing between these two entities becomes more difficult. When there is clinical suspicion of an LAA mass, the presence of a myxoma can be diagnosed early with myocardial perfusion contrast echocardiography.
ConclusionsDistinguishing between LAA thrombi and myxomas preoperatively using echocardiography is very difficult because of morphological similarities between these two entities. Histopathological examination of the surgically removed mass is a precise method for diagnosing LAA myxomas.
DisclosureAuthors report no conflict of interest.
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3. Malik L, Borgohain S, Gupta A, Grover V, Gupta VK. Left atrial appendage myxoma masquerading as left atrial appendage thrombus. Asian Cardiovasc Thorac Ann 2013; 21: 205-207.
4. Turhan S, Kilickap M, Candemir B, Berkalp B, Eren NT, Akgun G. Three unusual myxomas originating from the left atrial appendage: a case report. J Am Soc Echocardiogr 2005; 18: 694.
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Copyright: © 2016 Polish Society of Cardiothoracic Surgeons (Polskie Towarzystwo KardioTorakochirurgów) and the editors of the Polish Journal of Cardio-Thoracic Surgery (Kardiochirurgia i Torakochirurgia Polska). This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
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