Left Ventricular to Right and Left Atrial Shunts Post–Myxoma Resection: A Multimodality Imaging Perspective

Figure 1. Two-dimensional TEE focused on the left atrium (LA) with simultaneous orthogonal long-axis (A) and three-dimensional volume-rendered short-axis, end-systolic images (B), demonstrates a large mass (arrow) attached via a pedicle to the middle and anterior side of the interatrial septum (IAS), near the left ventricular outflow tract (LVOT) and the aortic-mitral curtain. CMR, balanced steady-state free precession sequence, four-chamber (C) and basal short-axis (D) diastolic views, demonstrates the large, irregular mass (arrow) location and morphology. AO, Aorta; LV, left ventricle; RA, right atrium; RV, right ventricle.

Figure 2. Two-dimensional TTE with color flow Doppler, parasternal long-axis (A), zoomed apical four-chamber (B), and three-chamber (C) systolic views obtained immediately after myxoma resection, demonstrates new mild to moderate eccentric MR with indeterminate etiology due to technical difficulty.

Figure 3. Two-dimensional TEE, aortic valve short-axis systolic view without (A) and with (B) color flow Doppler, long-axis (140°) left ventricular outflow tract (LVOT) view (C) and three-dimensional volume-rendered display (D), demonstrates both the acquired Gerbode defect (red arrow) and the LVOT–mitral anterior leaflet shunts with high-velocity turbulent flow patterns. IAS, Interatrial septum; LA, left atrium; LV, left ventricle; LVOT, left ventricular outflow tract; MV, mitral valve; RA, right atrium; RV, right ventricle.

Figure 4. Three-dimensional TEE with multiplanar reconstruction in two simultaneous orthogonal systolic views, an en face short-axis view and volume-rendered reconstruction without (A) and with (B) color flow Doppler, demonstrates the LV–left atrial defect (arrow) at the base of the anterior mitral valve leaflet with a high-velocity, turbulent flow pattern; using photorealistic volume-rendered, surgeon’s view displays without (C) and with color flow Doppler (D), the small LV–left atrial defect (arrow) is readily visualized in the surgeon’s view. 3D, Three-dimensional; AO, aorta; LA, left atrium; RA, right atrium.

Figure 5. CMR, basal short-axis images, balanced steady-state free precession (A), gradient echo (B), and phase-encoding (velocity encoding 200 cm/s) (C) sequences, demonstrates the small LV–to–right atrial (yellow arrow) and LV–to–left atrial (red arrow) shunts. LA, Left atrium; LVOT, LV outflow tract; RV, right ventricle; RA, right atrium.

Figure 6. Timeline of clinical presentation, diagnostic imaging, and surgery. From left to right: (A1) two-dimensional (2D) TTE, apical four-chamber view, demonstrates the left atrial myxoma (star); (A2) CMR apical four-chamber view demonstrates the LA myxoma (star); (B1) postoperative chest radiography demonstrates new permanent pacemaker implant; (B2) 2D TTE, apical four-chamber view, demonstrates a large loculated pericardial effusion; (C1) 2D TEE, long-axis LV outflow tract (LVOT) view with color flow Doppler, demonstrates flow into the left atrium (LA); (C2) CMR, basal short-axis views of the LVOT, demonstrates mitral valve (MV) perforation; (D1) three-dimensional TEE, volume-rendered reconstruction with color flow Doppler, surgeon’s view, demonstrates anterior MV perforation; and (D2) 2D TEE, aortic valve short-axis view with color flow Doppler, demonstrates the acquired Gerbode shunt. AO, Aorta; CHB, complete heart block; LVOT, LV outflow tract; RA, right atrium.

Figure 7. Intraoperative photograph through a small incision on the anterior side of the aorta just above the aortic valve demonstrates the acquired Gerbode defect in relation to the LV outflow tract (LVOT) (A) and the acquired basal mitral valve annular defect (covered by the metal probe) in relation to the acquired Gerbode defect (B).