Right Ventricular Myxoma with Partial Right Ventricular Outflow Tract Obstruction

A 58-yr-old asymptomatic man with a family history of early coronary artery disease presented to his family practitioner for routine evaluation. Because his electrocardiogram demonstrated T wave abnormalities, further testing was performed, including a transthoracic echocardiography examination. The latter examination demonstrated a well circumscribed ellipsoid mobile mass in the right ventricular outflow tract (RVOT) with RVOT obstruction. The patient was scheduled for excision of the intracardiac mass via midline sternotomy using cardiopulmonary bypass. To prevent hemodynamic instability during anesthetic induction, he received 1000 mL of IV crystalloid to maintain preload and inotropic support was avoided. Femoral arterial-femoral venous cannulation was performed for cardiopulmonary bypass initiation in case complete RVOT obstruction with hemodynamic collapse occurred. Intraoperative transesophageal echocardiography confirmed a pedunculated right ventricular mass with partial obstruction of the RVOT (Figs. 1, 2) (please see video loop available at www.anesthesia-analgesia.org). The mid-esophageal long-axis view demonstrated a right ventricular mass attached to the right ventricular free wall (Fig. 1). The right ventricular inflow-outflow tract view demonstrated flow acceleration around the tumor by color flow Doppler (please see video loop available at www.anesthesia-analgesia.org), which was present throughout the cardiac cycle confirming partial obstruction. Because of a nonfavorable interception angle, we were unable to obtain a pulse wave Doppler measurement across the obstruction. There was no significant tricuspid regurgitation or right ventricular hypertrophy. Transesophageal echocardiography findings of severe RVOT obstruction may include complete end-systolic obliteration of the RVOT, tricuspid regurgitation with bowing of the intraatrial septum to the left, and hepatic venous flow reversal. Right ventricular dilation and/or hypertrophy would furthermore suggest significant increased right-sided pressures. After resection, the mass was histologically identified as a myxoma. The patient made an uneventful postoperative recovery and was discharged home on postoperative day 6.Figure 1.: Mid-esophageal long axis view demonstrating a right ventricular mass attached to the right ventricular free wall.Figure 2.: Right ventricular inflow-outflow tract view demonstrating a right ventricular mass.Primary cardiac masses are rare and usually benign (1). Cardiac neoplasms may lead to significant morbidity and mortality by obstructing blood flow and causing arrhythmias and emboli (1). Myxomas are usually seen in adults, accounting for 25%–40% of all cardiac tumors from birth to adolescence. The majority of myxomas (75%) are located in the left atrium whereas right ventricular myxomas are only found in 2%–4% of cases (1,2). Right-sided cardiac tumors can present with congestive heart failure, shortness of breath, syncope, fatigue, edema, jugular venous distention, ascites, night sweats, and pericardial effusion. Vena cava syndrome, pulmonary embolism, and restrictive cardiomyopathy are some of the complications (1). The most important distinguishing feature of a myxoma is the characteristic narrow stalk, followed by tumor mobility and distensibility, although broad-based, non-mobile myxomas can also occur. Myxomas may be homogeneous or may have central areas of hyperlucency representing hemorrhage and necrosis. Calcification with echogenic foci may also be detected. In adults, the primary differential diagnosis for a solitary, intracavitary cardiac mass includes thrombus, myxoma, lipoma and nonmyxomatous neoplasms, most of which are malignant (1). Video Image 1: Right ventricular inflow-outflow tract view with color flow Doppler demonstrating continuous flow around the mass throughout the cardiac cycle.