Journal of Anesthesia

, Volume 29, Issue 1, pp 134–137 | Cite as

Role of intraoperative transesophageal echocardiography in detecting masked mitral regurgitation during left atrial myxoma surgery

  • Kyoko YamaguchiEmail author
  • Yasuhiro Koide
Clinical Report


Myxomas are the most common type of cardiac tumor. Mobile or large left atrial (LA) myxomas frequently cause functional mitral stenosis, and can lead to mitral regurgitation (MR). Difficulties have been associated with detecting masked MR jets and evaluating the severity of MR during LA myxoma surgery due to the presence of a prolapsing tumor and changes in blood flow. We herein presented a case of LA myxoma with significant MR diagnosed on intraoperative transesophageal echocardiography (TEE) prior to cardiopulmonary bypass. Repeated careful observations on TEE led to a confident diagnosis of MR and the selection of an additional appropriate procedure. This case study highlighted the importance of intraoperative TEE in supporting clinical decision-making for optimal mitral valve procedures during LA myxoma surgery.


Intraoperative transesophageal echocardiography Myxoma Mitral regurgitation 

Supplementary material

Supplementary material 1 (MPG 10334 kb). Preoperative transthoracic echocardiography showing the prolapsing tumor moving from the left ventricle to the left atrium during systole, and from the left atrium to the left ventricle during diastole (Parasternal LAX). On color-flow Doppler imaging, a color jet (arrow), suspected to be the mitral regurgitation jet, was observed in the left atrium, whereas a clinically significant mitral regurgitation jet was not detected. Apical 4-chamber view showing minor flow convergence (arrow) inside the left ventricle, which may be a sign of mitral regurgitation; however, a significant mitral regurgitation jet was not detected in the left atrium on color-flow Doppler imaging. Parasternal LAX = parasternal long-axis view; Apical 4CH = apical 4-chamber view; LV = left ventricle; RV = right ventricle; RA = right atrium; T = tumor

Supplementary material 2 (MPG 1034 kb). Intraoperative transesophageal echocardiography showing a protrusive mass moving into the left ventricle during diastole that obstructs transmitral inflow and causes severe mitral stenosis (ME 4CH). In color-flow Doppler imaging, the arrow indicates the proximal isovelocity surface area (PISA) in diastole, which depicts proximal flow convergence in the left atrium. On the other hand, color flow in red was observed around the tumor in the left atrium in systole. This color flow may be mitral regurgitation; however, it is difficult to distinguish true MR from turbulent flow around the prolapsing left atrial tumor. ME 4CH = midesophageal 4-chamber view; LA = left atrium; LV = left ventricle; RV = right ventricle

Supplementary material 3 (MPG 3866 kb). Mitral regurgitation jets (double arrow) on color-flow Doppler images (ME 4CH). The mitral regurgitation jet was directed posteriorly due to anterior leaflet prolapse (mainly) and was diverted by the tumor (a zoom view). The prolapsed middle segment of the anterior mitral valve leaflet (A2) and mitral regurgitation jet (double arrow) were observed on two-dimensional and color-flow Doppler images (ME LAX). This view also showed turbulent flow across the mitral valve, indicating mitral stenosis in diastole. ME 4CH = midesophageal 4-chamber view; ME LAX = midesophageal long-axis view; T = tumor; LV = left ventricle; RA = right atrium; RV = right ventricle; Ao = ascending aorta


  1. 1.
    Reynen K. Cardiac myxomas. N Engl J Med. 1995;333:1610–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Nardi C, Carlo M, Milano A, Bortolotti U. The wrecking ball effect of a right atrial myxoma. Eur J Cardiothorac Surg. 2000;17:338.CrossRefPubMedGoogle Scholar
  3. 3.
    Vohra HA, Vohra H, Patel RL. Cardiac myxoma with three recurrences. J R Soc Med. 2002;95:252–3.CrossRefPubMedCentralPubMedGoogle Scholar
  4. 4.
    Teng YH, Wang CW, Mao CC. Underdiagnosis of the severity of mitral regurgitation in left atrial myxoma. J Heart Valve Dis. 2010;19:806–7.PubMedGoogle Scholar
  5. 5.
    Germing A, Lindstaedt M, Mugge A, Laczkovics A, Fritz M. Severity of mitral regurgitation may be underestimated in the presence of a left atrial myxoma. J Heart Valve Dis. 2006;15:830–2.PubMedGoogle Scholar
  6. 6.
    Matsushita T, Huynh AT, Singh T, Hayes P, Armarego S. Mitral valve annular dilatation caused by left atrial myxoma. Heart Lung Circ. 2009;18:145–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Formica F, Sangalli F, Paolini G. Unusually large left atrial myxoma causing mitral valve occlusion and hiding a severe mitral regurgitation: a case report. Heart Surg Forum. 2006;9:E849–50.CrossRefPubMedGoogle Scholar
  8. 8.
    Lee JH, Lee GW, Kim OK, Hur JH, Choi BJ, Choi KJ, Cha TJ, Lee JW, Kim HS. A case of large left atrial myxoma presenting as atrial flutter. J Cardiovasc Ultrasound. 2008;16:59–62.CrossRefGoogle Scholar
  9. 9.
    Whitlock R, Evans R, Lonn E, Teoh K. Giant left atrial myxoma and associated mitral valve pathology. J Cardiothorac Vasc Anesth. 2007;21:103–5.CrossRefPubMedGoogle Scholar
  10. 10.
    Biasucci LM, De Benedittis G, Alecce G, Lombardo A, Loperfido F. Doppler analysis of pulmonary venous flow in left atrial myxoma. Chest. 1994;105:315–7.CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2014

Authors and Affiliations

  1. 1.Department of AnesthesiologyYokohama City University Medical CenterYokohamaJapan
  2. 2.Kanagawa Children Medical CenterYokohamaJapan
  3. 3.Hayama Heart CenterMiuraJapan

Personalised recommendations