Contralateral recurrence of atrial myxoma - case report and review of the literature.

Cardiac myxomas are the most frequent cardiac tumors, and they have the capability for recurrence years after resection, in the same or in different cardiac chambers. Hence, follow-up is important. Contralateral recurrences of myxoma are uncommon. We report a 7 year old boy who had a right atrial myxoma resected, and who had recurrent myxoma in the left atrium. The literature regarding such recurrence is reviewed.

The use of transesophageal echocardiography guidance of thrombolytic therapy in prosthetic mitral valve thrombosis.

BACKGROUND AND AIM OF THE STUDY: The aim of the study was to assess the use of transesophageal echocardiography (TEE) to guide thrombolytic therapy in prosthetic mitral valve thrombosis. METHODS: Twenty-nine consecutive cases of prosthetic mitral valve thrombus diagnosed between January 1995 and May 1998 were managed according to data obtained by TEE. Three patients with pedunculated thrombus and five in NYHA functional classes I-II were referred for surgery. Patients who refused surgery or who were in NYHA classes III-IV and had unpedunculated thrombus were selected for thrombolytic therapy. Twenty-one patients (seven males, 14 females; mean age 47 +/- 8 years) received streptokinase for thrombolysis. RESULTS: The mean period from valve replacement surgery was 36 +/- 23 months, and mean time from onset of symptoms 9.2 +/- 14.3 days. Anticoagulant use was inadequate in 18 (86%) patients. Fourteen cases (66%) were NYHA class IV, four (19%) in class III, and three (15%) in class II. Ten patients (48%) were in atrial fibrillation. During the first 24 h of thrombolytic therapy, mean mitral valve peak and mean gradients fell from 25.6 +/- 4 and 13.8 +/- 2.5 mmHg to 11.7 +/- 5.3 and 7.1 +/- 3.1 mmHg respectively (p <0.0001). Five cases with inadequate response to thrombolysis were treated for an additional 24 h. The mitral valve area increased from 1.0 +/- 0.1 cm2 to 2.3 +/- 0.7 cm2 after the first month (p <0.0001). Complete early success in thrombolysis was achieved in 17 (81%) cases, three cases (14%) had partial success, and one case (5%) was referred for surgery on the third day because of failed thrombolysis. Two minor skin bleedings (9%) not requiring transfusion were attributed to thrombolytic therapy. One case (5%) of successful thrombolysis had a non-fatal stroke after therapy and one (5%) was referred for surgery for recurrent prosthetic mitral valve thrombosis at six months' follow up. None of the surgically treated patients died. CONCLUSION: Guidance of thrombolysis by TEE may reduce, but not eliminate, the risk of thromboembolic complications. Response to thrombolysis became apparent within 24 h, but extending treatment beyond this time provided no additional short-term benefit.

Left atrial thrombus detection with multiplane transesophageal echocardiography: an echocardiographic study with surgical verification.

BACKGROUND AND AIM OF THE STUDY: The detection of left atrial thrombus (LAT) is especially important in patients being evaluated for percutaneous mitral valvuloplasty and elective cardioversion for atrial fibrillation. Transesophageal echocardiography (TEE) is widely used for this indication. This study was undertaken to validate the use of multiplane TEE to detect LAT in the setting of rheumatic mitral valve disease. METHODS: The study population comprised 262 patients (103 men, 159 women, mean age 42.2+/-13.1 years) who underwent open heart surgery for rheumatic mitral valvular disease between January 1994 and October 1997. Of these patients, 178 had mitral stenosis and 84 mitral regurgitation. All patients were examined with multiplane TEE less than three days before valvular surgery. RESULTS: The presence or absence of LAT was confirmed at surgery by direct inspection of the left atrium. Left atrial thrombi were detected by TEE in 34 patients (14 men, 20 women; mean age 51+/-8 years). The presence of all 34 thrombi found by multiplane TEE was confirmed during surgery. Only one thrombus was confirmed surgically among 228 patients shown thrombus-negative by multiplane TEE. The sensitivity, specificity, positive and negative predictive value and diagnostic accuracy for multiplane TEE were 97, 100, 100, 99.6 and 99.6%, respectively. CONCLUSION: Multiplane TEE is exquisitely sensitive for the detection of LAT.