Role of intraoperative transesophageal echocardiography in detecting masked mitral regurgitation during left atrial myxoma surgery
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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.
KeywordsIntraoperative transesophageal echocardiography Myxoma Mitral regurgitation
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