We report on a woman with previously unknown left atrial myxoma, who underwent percutaneous coronary intervention. 45 months after the initial coronary angiography, echocardiography demonstrated a large atrial myxoma, which was not seen echocardiographically before. The retrospective analysis of the pre-intervention coronary angiography revealed atypical vessels in the atrial septum, which are interpreted as early signs of myxoma

Adrian Constantin Borges

Fabian Knebel

GA Fueredi

Gert Baumann

Hans-Peter Dübel

J Daoud

J Van Cleemput

K Reynen

LM Shapiro

N Vassiliadis

R Douniau

S Malekzadeh

Volker Gliech

WC Roberts

WH Chow

Wolfgang Konertz

Wolfgang Rutsch

WS Colucci

WT Pochis

English

PubMed

Springer - Publisher Connector

BioMed CentralCardiovascular Ultrasound
ssOpen AcceCase report
Atypical vessels as an early sign of intracardiac myxoma?
Hans-Peter Dübel1, Fabian Knebel*1, Volker Gliech1, Wolfgang Konertz2, 
Wolfgang Rutsch1, Gert Baumann1 and Adrian Constantin Borges1
Address: 1Medical Clinic for Cardiology, Angiology, Pulmology, Charité Campus Mitte, University medicine Berlin, Germany and 2Director of the 
Clinic of Cardiovascular Surgery, Charité Campus Mitte, University Medicine Berlin, Germany
Email: Hans-Peter Dübel - hans-peter.duebel@charite.de; Fabian Knebel* - fabian.knebel@charite.de; Volker Gliech - volker.gliech@charite.de; 
Wolfgang Konertz - wolfgang.konertz@charite.de; Wolfgang Rutsch - wolfgang.rutsch@charite.de; Gert Baumann - gert.baumann@charite.de; 
Adrian Constantin Borges - adrian.borges@charite.de
* Corresponding author    
MyxomaCoronary Artery Disease
Abstract
We report on a woman with previously unknown left atrial myxoma, who underwent
percutaneous coronary intervention. 45 months after the initial coronary angiography,
echocardiography demonstrated a large atrial myxoma, which was not seen echocardiographically
before. The retrospective analysis of the pre-intervention coronary angiography revealed atypical
vessels in the atrial septum, which are interpreted as early signs of myxoma.
Background
Primary cardiac tumors are rare disorders, with an inci-
dence of 0.02% at autopsy. Three quarters of the primary
tumors of the heart are benign, half of which are myxomas
[1].
As noninvasive cardiac imaging becomes widely available,
with increasing resolution provided by echocardiography,
computed tomography and magnetic resonance imaging,
cardiac tumors are being diagnosed more often. Angiogra-
phy, apart from its preoperative role to rule out concomi-
tant coronary artery disease, is rarely needed for the
diagnostic work-up of cardiac tumors.
This report describes the delayed presentation of a left
atrial myxoma which was not depicted in an initial coro-
nary angiography performed 51 months earlier in a
woman with chest pain.
Case Report
A 62-year-old woman with known metabolic syndrome
was referred to our clinic to exclude coronary artery dis-
ease invasively. She has been experiencing chest pain for
four months which has not increased in frequency or
duration since it started. She denied pain at rest, nocturnal
pain, difficulty breathing, or palpitations. An echocardio-
graphic stress examination revealed significant ischemia
with anteroseptal hypokinesia. Cardiac chambers were
morphologically normal. The "baseline" echocardiogra-
phy and stress echo was unsuspicious of a left atrial
myxoma (Fig. 1).
Coronary angiography revealed coronary artery disease
with a stenosis of the proximal left anterior descending
coronary artery (LAD) near the left main stem. A stent was
implanted in the proximal LAD with no residual stenosis.
The ventricle was morphologically normal.
Published: 13 August 2004
Cardiovascular Ultrasound 2004, 2:13 doi:10.1186/1476-7120-2-13
Received: 19 July 2004
Accepted: 13 August 2004
This article is available from: http://www.cardiovascularultrasound.com/content/2/1/13
© 2004 Dübel et al; licensee BioMed Central Ltd. 
This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 7
(page number not for citation purposes)
Cardiovascular Ultrasound 2004, 2:13 http://www.cardiovascularultrasound.com/content/2/1/13Stress echocardiography: long axis view (baseline)Figure 1
Stress echocardiography: long axis view (baseline). No sign of myxoma in left chamber or in left atrium. LA = left atrium, LV = 
left ventricle, Ao = Ascending aorta (with kind permission of Dr. Herbst, Potsdam)Page 2 of 7
(page number not for citation purposes)
Cardiovascular Ultrasound 2004, 2:13 http://www.cardiovascularultrasound.com/content/2/1/13A coronary angiography performed 13 months after stent
implantation showed no re-stenosis and a normal left
ventricle. No echocardiogram was performed at this time
32 months after the control coronary angiography, the
patient was readmitted because of increasing dyspnoea
and palpitations. A transthoracic echocardiography dis-
closed a big (70 × 30 mm) mass in the left atrium attached
to the interatrial septum. The tumor prolapsed into the
left ventricle obstructing the mitral valve orifice (Fig 2).
The mean pressure gradient across the mitral valve was 8
mm Hg.
A subsequent coronary angiography and LV and RV cath-
eterization detected a mean diastolic pressure gradient of
12 mm Hg between the pulmonary capillary wedge and
the left ventricular enddiastolic pressure, and no re-steno-
sis of the LAD stent. The angiography was notable for a
large area with small atypical, tortuous vessels in the
region of the interatrial septum. These vessels were shown
to originate from branches of the right coronary artery
(RCA) and the circumflex coronary artery (RCX). (Fig. 5)
Surgery was promptly performed and the tumor was suc-
cessfully excised. Histology confirmed the diagnosis of a
cardiac myxoma.
A retrospective analysis of the initial coronary angiogra-
phies (baseline, 13 and 45 months) disclosed the atypical
vessels in a small area of interatrial septum (Fig. 3, 4, 5).
Discussion
Myxomas are benign but potentially dangerous with dis-
turbance of rhythm, peripheral embolization or mechan-
ical valvular obstruction, of the atrial or ventricular cavity
[2,3].
The site, mobility, and size of the myxoma determine the
clinical course. Some authors found no correlation
Echocardiography (45 months) long axis viewFigure 2
Echocardiography (45 months) long axis view. Myxoma in the left atrium prolapsing into the left ventricle. LV = left ventricle, 
My = myxomaPage 3 of 7
(page number not for citation purposes)
Cardiovascular Ultrasound 2004, 2:13 http://www.cardiovascularultrasound.com/content/2/1/13between the size of the tumor and the clinical picture [4],
others reported symptoms with left atrial myxomas
weighting more than 70 g [5]. The rate of growth of myxo-
mas is not exactly known [5,6]. An increase in size of 1.8
– 5.8 cm/year and in weight of up to 14 g/year was
reported [7,8]. The myxoma of our patient reached 70 ×
30 mm before being symptomatic.
Myxomas presenting with systemic embolism or intracav-
itary obstruction can be easily detected non-invasively.
The early depiction of small intracardiac tumors by means
Right coronary artery (baseline) in 90 degree LAO projectionF ure 3
Right coronary artery (baseline) in 90 degree LAO projection. White arrow = atypical vessels in the interatrial septumPage 4 of 7
(page number not for citation purposes)
Cardiovascular Ultrasound 2004, 2:13 http://www.cardiovascularultrasound.com/content/2/1/13of angiography relies on the detection of atypical vessels
supplied by branches of the left or right coronary artery.
Our case demonstrates that this early angiographic sign is
difficult to find. However, vascular malformations are not
pathognomonic for myxomas [9] and stromal tumors,
such as myxomas, have generally poor blood supply,
hence a coronary angiographic finding with a neo-vascu-
larized or highly vascularized intracardiac area is more
suggestive for other type of cardiac neoplasm. A cluster of
small, tortuous and dilated vessels is also seen in old and
organised thrombi, haemangiomas and venous malfoma-
Left coronary artery (13 months) in 45 degree LAO and 30 degree CRAN projectionFigure 4
Left coronary artery (13 months) in 45 degree LAO and 30 degree CRAN projection. White arrow = atypical vessels in the 
interatrial septumPage 5 of 7
(page number not for citation purposes)
Cardiovascular Ultrasound 2004, 2:13 http://www.cardiovascularultrasound.com/content/2/1/13tions [10]. The size of malformation has no relation to the
size of the tumor [11].
It has been reported in the literature that myxomas can be
induced by radiation [12,13]. Between the first presenta-
tion to our clinic and the diagnosis of myxoma, the
patient underwent two coronary angiograms including
stenting, with a cumulative radiological exposure of about
30 mSv (corresponding to at least 1500 chest X-rays). To
Right coronary artery (RCA) in 60 degree LAO position (45 months, pre-operative coronary angiography)F ure 5
Right coronary artery (RCA) in 60 degree LAO position (45 months, pre-operative coronary angiography). White arrow = 
atypical vessels in the interatrial septumPage 6 of 7
(page number not for citation purposes)
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our knowledge, the patient did not undergo any other rel-
evant radiation exposure in the past.
In the present case, a retrospective analysis of the patient
angiographies disclosed the atypical vessels which were
initially overseen. These vessels could have probably been
interpreted as an early sign of myxoma.
Author's contributions
HPD and FK have written the manuscript and have
equally contributed to this publication. HPD, VG and WR
have performed the coronary angiographies. WK has per-
formed cardiac surgery. HPD, ACB, FK and GB partici-
pated in the design and coordination of the final
manuscript. All authors have read and approved the final
manuscript.
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Atypical vessels as an early sign of intracardiac myxoma?

Crossref

Abstract We report on a woman with previously unknown left atrial myxoma, who underwent percutaneous coronary intervention. 45 months after the initial coronary angiography, echocardiography demonstrated a large atrial myxoma, which was not seen echocardiographically before. The retrospective analysis of the pre-intervention coronary angiography revealed atypical vessels in the atrial septum, which are interpreted as early signs of myxoma.</p

Rutsch Wolfgang

Konertz Wolfgang

Gliech Volker

Knebel Fabian

Dübel Hans-Peter

Baumann Gert

Borges Adrian

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Benigne Tumoren des Herzens [Benign tumors of the heart].

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E: Primary tumors of the heart. In: Heart Disease. A Textbook of Cardiovascular Medicine 5th edition. Edited by: Braunwald E. Philadelphia:

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Atypical vessels as an early sign of intracardiac myxoma?

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