CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 1, January – April 2024 AFRICA 31 appendage.12 Myxomas are usually round or oval, broad-based, pedunculated tumours that grow at a rate of about 0.15 cm per month.13 In our study, myxoma localisation was in the left atrium in 25 patients (73.5%). Cardiac myxomas are benign tumours but often result in serious complications due to their asymptomatic features.14 Because of the high blood flow, the ruptured tumour fragments can reach all parts of the body, and because they are asymptomatic, patients with undiagnosed cardiac myxomas are at risk of experiencing systemic and pulmonary embolism and even intracardiac obstruction.15 Embolism from myxomas may cause various complications such as myocardial infarction, stroke, heart failure, other organ infarction and limb ischaemia.14 In our study, three patients (15.8%) were diagnosed with ischaemic stroke. Evaluation of other concomitant cardiac and non-cardiac health problems in patients with cardiac myxoma is important for management and treatment strategies.3 The use of echocardiographyhasgreatly facilitatedthediagnosisof structural heart pathologies and cardiac myxomas.1 Echocardiography is the most commonly used diagnostic method for accurate and rapid pre-operative evaluation of myxoma patients.14 In previous studies, it was emphasised that the heart valves and chambers should be carefully examined with both TTE and TEE due to concomitant cardiac pathologies.16 TEE and threedimensional echocardiography should be performed to clarify the shape, size and mobility of the cardiac myxoma.3 In addition, clinical features and histopathological type of the myxoma can be predicted and treatment strategies can be determined by echocardiography.1 CT and MRI, which are other diagnostic methods, can distinguish between tumour and non-tumour mass, benign and malignant mass, and information about the characteristics and spread of the tumour can be obtained.13 Radiological imaging of these lesions, especially with CT or MRI, can provide an accurate assessment of the size, location and attachment point of these lesions and assist in surgical planning.17 In recent years, cardiac MRI has become an indispensable method for comprehensive evaluation, clinical diagnosis and treatment guidance of heart tumours due to its multi-plane image reconstruction capability, adequate spatial resolution, excellent soft tissue characterisation and capacity to distinguish different tissue features.8 In addition, cardiac MRI allows determination of the location, homogeneity, morphology, extent, margin, mobility and valve dysfunction of heart masses and can evaluate the relationship between tumour and lung, pericardium or mediastinum.18 Contrast-enhanced MRI is preferred to define further characterisation of cardiac myxomas, but CT coronary angiography may be more used for differential diagnosis of the myxoma and thrombus.19 In contrast-enhanced cardiac MRI, contrast enhancement describes the vascularity of the tumour and its relationship to the blood vessels, and further illustrates the impact of tumours on tissue characterisation, cardiac function and haemodynamics, and the relationship between cardiac tumours and extracardiac structures. This advantage of contrast-enhanced cardiac MRI is of great importance in tumour treatment and prognosis evaluation.20 Cardiac MRI also has disadvantages, one of which is that, due to its lower temporal resolution, it cannot provide an advantage over echocardiography in the evaluation of heart or valve tumours that are less than 10 mm in diameter, nearly invisible, and highly mobile.8 Other limitations of cardiac MRI are its high cost, long acquisition time, and unavailability of use in patients with implanted cardiac devices such as pacemakers or intracardiac defibrillators, those with haemodynamic instability or those with breathlessness and claustrophobia.21 Cardiac CT has become a second-line diagnostic method, with increasing use in the evaluation of heart masses, especially in cases where other imaging methods are contra-indicated or under-evaluated.8 With the emergence and advancement of technologies such as cardiac CT, multidetector CT, helical CT and electrocardiographic-gated CT, cardiac masses have achieved submillimetre spatial resolution and shorter scanning time, minimising motion-related artifacts, with improved temporal resolution and imaging quality defined more accurately.22 Cardiac CT has the ability to characterise tissue by evaluating density and perfusion, and the use of contrast-enhanced CT provides significant benefits, especially in determining the differential diagnosis of cardiac masses and evaluating the vascular distribution and fibrous component of tumours.23 Cardiac CT is reported to be the most appropriate and preferred imaging technique for the evaluation of cardiac tumour calcification and other non-cardiac structures when compared to other imaging modalities.22 Limitations of cardiac CT are exposure to radiation, risk of adverse events from the contrast medium used, and lower soft tissue resolution compared to echocardiography or cardiac MRI.8 There is still no consensus on whether or not to perform pre-operative coronary artery angiography in patients with cardiacmyxoma in the presence of ischaemic symptoms.24 Because cardiac myxoma can easily be diagnosed by echocardiography, some authors have recommended that myxomas be resected as soon as the diagnosis is made.25 Other authors have recommended that coronary artery angiography be performed only in patients with chest pain or over the age of 40 years.26 Sometimes coronary angiography can also be useful to identify high-level vascular tumours such as angiosarcoma.25 In clinical practice, echocardiography and cardiac MRI are the primary imaging modalities for the diagnosis and treatment of cardiac tumours, while cardiac CT is a powerful and valuable complementary tool. In our study, echocardiography was the most commonly used diagnostic method for pre-operative diagnosis of myxomas in both symptomatic and asymptomatic patients and for detecting the presence of residue of postoperative residual tumours and the recurrence of tumours. In the follow up, if there was a suspicious appearance in the area where the myxoma was excised, the possibility of recurrence was followed up with cardiac CT or MRI. In addition, in our study, cardiac CT and MRI examinations were performed on myxoma patients whose location of anatomical attachment could not be determined by echocardiography and could not be clearly differentiated from thrombus. We also performed coronary artery angiography in all myxoma patients. Although it is generally accepted that intracardiac masses require surgical intervention, there is no consensus on the timing of excisional surgery.1 Surgical excision of cardiac myxomas is the only remedial treatment modality, except for a few recurrences in long follow up times in patients with low operative risk.24 While debate continues about the timing of the surgery,
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