CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 1, January – April 2024 AFRICA 27 Clinical characteristics, diagnostic methods and results of surgically treated histologically benign cardiac myxomas Durmuş Alper Görür, Hüseyin Şaşkin Abstract Background: Myxomas are primary cardiac tumours that may be detected incidentally due to embolic events, intracardiac obstructive features or non-specific structural symptoms. The aim of this study was to share our experience of clinical features, diagnostic methods, surgical procedures and postoperative follow up of surgically treated cardiac myxomas. Methods: Data of 34 patients who underwent surgery for a cardiac myxoma between January 2006 and June 2022 were retrospectively analysed. Group 1 (n = 19) consisted of patients who were symptomatic and group 2 (n = 15) patients were asymptomatic. The medical records of the patients, their clinical status, diagnostic methods, operation information and postoperative course data were collected and recorded. Results: A total of 34 patients (16 female; mean age 54.5 ± 8.8 years) underwent cardiac myxoma resection with cardiopulmonary bypass. Fifteen (44.1%) patients were diagnosed incidentally with asymptomatic myxoma. An additional cardiac surgical procedure was performed in six patients (17.7%). The 34 cardiac myxomas that were surgically resected were localised in the left atrium in 25 patients (73.5%) and in the right atrium in nine patients (26.5%). Patients’ most common symptoms were dyspnoea (42.1%), palpitations (21.1%), ischaemic stroke (15.8%) and syncope (10.5%). There was no incident of 30-day mortality and no recurrence was observed in any patient during the follow-up period. The duration of surgical intervention in symptomatic patients was significantly shorter than in asymptomatic patients (p = 0.0001), but there was no statistical difference in terms of characteristics. Conclusion: Myxomas are benign tumours, but they are serious pathologies that require early treatment because of signs of obstruction, embolic complications and confusion, with left atrial thrombus in the differential diagnosis. Keywords: cardiac myxoma, cardiac surgery, clinical characteristics Submitted 8/11/22; accepted 12/12/22 Published online 7/2/23 Cardiovasc J Afr 2024; 35: 27–34 www.cvja.co.za DOI: 10.5830/CVJA-2022-069 Primary cardiac tumours are rare, accounting for only five to 10% of all neoplasms of the heart and pericardium, and about 80% are benign, of which more than half are myxomas.1 Myxomas are very rare, with an incidence of 0.0017 to 0.19% in autopsies; left atrial myxomas are the most common and constitute 75% of all tumours in this locality.2 Cardiac myxomas are the most common benign cardiac tumours, with various clinical presentations.3 These primary tumours of the heart often occur in middle age and are more common in women than men.4 Myxomas usually occur sporadically, but familial myxomas have also been reported rarely.1 Although structural symptoms are common in patients with a cardiac myxoma, this benign tumour has the danger of cerebral or peripheral infarction, intracardiac obstruction, syncope, and sudden death due to systemic embolisation.5 These symptoms depend on the location, size and mobility of the tumour. On physical examination, approximately one-third of these patients will have an early diastolic murmur (‘tumour plop’).2 The incidence of incidentally diagnosed asymptomatic cardiac myxoma ranges from zero to 25% in the literature.3 Identification of cardiac tumours is usually done by imaging [echocardiography, computed tomography (CT) and cardiac magnetic resonance imaging (MRI)] methods. Definitive diagnosis of a cardiac myxoma is made after surgical removal of the tumour and histopathological evaluation of the removed sample.1 Although transthoracic echocardiography is the first and most common imaging modality used for diagnosis of these patients, cardiac MRI has come to the forefront in the last decade as the primary imaging modality in the evaluation of patients with cardiac tumours.6 Cardiac MRI provides the best assessment of the location and functional impact of cardiac masses in any imaging plane without exposing patients to ionising radiation.7 In particular, cardiac MRI outperforms the most commonly used echocardiography in determining the nature of cardiac lesions and can distinguish cardiac myxomas from thrombus in the cardiac chambers.6 In recent years, cardiac CT has been used frequently to evaluate benign primary cardiac tumours and to provide detailed information about anatomical and tissue features.8 The most effective treatment of choice for myxomas is surgical removal.9 Asymptomatic tumours due to mitral valve obstruction, or coronary artery and/or peripheral artery occlusion as a result of embolic complications should also be surgically removed.2 While the surgical mortality rate was zero to 3% in earlier literature, the postoperative mortality rate ranged from zero to 12%. Relapse cases have been described, albeit very rarely and the overall risk of recurrence for sporadic tumours is only one to 3%.1 In this study, we aimed to share our clinical experience, Cardiovascular Surgery Clinic, Derince Training and Research Hospital, Health Sciences University, Kocaeli, Turkey Durmuş Alper Görür, MD, alper1976md@yahoo.com Hüseyin Şaşkin, MD
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