DK2985_C000 1..28 - AlSharqia Echo Club

504 Transesophageal EchocardiographyAPPROXIMATE FREQUENCY OF CARDIAC TUMORS BY TYPE AND SITECARDIAC TUMORSPrimary cardiac tumorsMetastatic tumorsBenign 75% Malignant 25%(virtually allsarcomas)Other 50% Myxomas 50%20-40 times morefrequent than primarytumors of the heartRightheart20%Leftheart80%Rightheart25%Leftheart75%Rightheart75%Leftheart25%Rightheart60%Leftheart40%Figure 23.10 Classification of cardiac tumors. [Adapted with permission from Gopal et al. (9).]A. Benign Cardiac Tumors1. MyxomasMyxomas constitute nearly 50% of all histologicallybenign tumors of the heart. They are usually pedunculated,polypoid, and friable. Some may have a smooth surfaceand may be round. These tumors generally have a jellylike,globular appearance. Echo-free spaces may be presentwithin the mass, corresponding to areas of hemorrhageor necrosis. Areas of calcification can also be seen. Atthe time of diagnosis, myxomas have an average size of4–8 cm but have been known to reach up to 15 cm.Approximately 75% of cardiac myxomas classicallyinvolve the LA, presenting as a mobile echogenic massfound in the body of the LA, usually attached to theatrial septum by a stalk in the region of the fossa ovalis(Figs. 23.11 and 23.12). An additional 10% arise fromother sites within the LA including the posterior, theanterior wall or the LAA. Most of the remainder ofmyxomas originate from the RA; the right or left ventricle(LV) is implicated in 5% of the series. Some cases,arising from the mitral valve and the IVC, have alsobeen reported. The diagnosis may be difficult to establishwhen the stalk is short and difficult to visualize, whenthe tumor is not very mobile or when the myxoma arisesfrom an atypical location (9,10).Transesophageal echocardiography is highly sensitiveto detect left atrial tumors and is particularly useful in delineatingthe attachment or the stalk of the tumor, a significantcontribution to narrowing the differential diagnosis.Beside accurate description of the size, shape, location,and attachment of the myxoma, TEE can also evaluatethe degree of mitral inflow obstruction by the mass.Tumors with a long pedicle can be seen moving back andforth through the mitral orifice during the cardiac cycle.Right atrial myxomas tend to be broader-based thanleft-sided tumors and involve a larger area of the atrialwall or septum. Ventricular myxomas may originatefrom the ventricular septum with either a pedunculatedor sessile appearance.(A)(B)MYXOMALARALVOTRVFigure 23.11 Mid-esophageal 428 view of a left atrial myxoma before surgical resection. Note that the pedicle of the myxoma isattached to the interatrial septum (LA, left atrium; LVOT, left ventricular outflow tract; RA, right atrium; RV, right ventricle).