left atrial myxoma causes paradoxical motion of the catheter; posterior

Transcription

1 Am JRoentgenolla6:II55-II58, 1976 ABNORMAL LEFT VENTRICULAR CATHETER MOTION: AN ANCILLARY ANGIOGRAPHIC SIGN OF LEFT ATRIAL MYXOMA ABsTRACT: J. M. RAU5CH, R. T. REINKE, K. L. PETERSON,2 AND C. B. HIGGINs The normal motion of a left ventricular catheter parallels that of the aortic root; it moves anterior during systole and posterior during diastole. In contrast, a prolapsing left atrial myxoma causes paradoxical motion of the catheter; posterior during systole and anterior during diastole. Paradoxical motion was found in each of five cases of prolapsing left atrial myxoma (no false negatives), and in six out of 6i controls (six false positives). In the false positive cases, the catheter was not positioned on the ventricular floor and usually only minor degrees of abnormal motion were present. Paradoxical motion of the left ventricular catheter is an ancillary angiographic finding in prolapsing left atrial tumor. The initial angiographic diagnosis of a left atrial myxoma was made over 2 decades ago [i]. False positive diagnoses due to atrial thrombus [2] and false negative diagnoses due to inadequate opacification of cardiac chambers still occur [s]. A recent review of myxomas indicated that preoperative angiography failed to detect left atrial myxomas in three of 13 cases []. In recent years, echocardiography has greatly enhanced diagnostic potential [, 6], but it is still imperative to angiographically confirm the diagnosis and define the anatomical relationships prior to surgical intervention. We have recently noted that the prolapsing atrial tumor may impinge on the left yentricular catheter during diastolic filling of the left ventricle and thereby provide the angiographer with an important clue to the presence of a left atrial myxoma during catheterization. SUBJECTS AND METHODS To assess specificity of left ventricular catheter motion in left atrial myxoma, 6i adult patients undergoing left ventricular catheterization were evaluated. Five had left atrial myxomas, 20 had coronary artery disease, and 36 had various valvular lesions (five mitral stenosis, 17 mitral insufficiency, one aortic insufficiency, and 13 multivalvular disease). A no. 7 French Lehman catheter was used. Catheter motion was measured in the lateral projection at three points along the vertical catheter axis during end-systole and enddiastole. To avoid artifactual motion, measurements of motion were taken only after contrast injection had ceased. In addition, anteriorposterior motion of the aortic root in the lateral projection was measured in 25 patients. Any anterior catheter motion during diastole was considered to be abnormal motion. RESULTS In the patients without left atrial myxoma, the entire catheter moved anteriorly in systole and posteriorly in diastole (fig. i). This movement closely approximated the movement of the aortic root. The influx of blood from the left atrium during rapid filling and during the atrial contraction had little effect on the movement of the catheter, even in patients with mitral stenosis and mitral insufficiency. On the other hand, abnormal catheter motion was demonstrated in each patient with left atrial myxoma. This abnormal motion was characterized by posterior rather than anterior motion during systole Division of Cardiovascular Radiology, University Hospital, University of California at San Diego, and Veterans Administration Hospital, 5an Diego, California Address reprint requests to R. T. Reinke at the Veterans Administration Hospital. 2 Division of Cardiology, University Hospital, University of California at 5an Diego. 55

2 I I RAUSCH ET AL. FIG. x.-systolic (A) and diastolic (B) frames from lateral cineangiogram of normal patient. Composite line drawing of systolic (dashed lines) and diastolic (so/id /ines) frames. Catheter normally moves posteriorly during diastole (arrow). and anterior movement or bowing of the catheter in diastole (paradoxical motion) (fig. 2). There were no false negative cases. Of the six false positive cases, all occurred among patients with valvular disease. Closer scrutiny of these cases indicated that the catheter was not positioned on the ventricular floor, which resulted in its apparently abnormal anterior motion in h!. diastole. The amount of catheter motion and aortic root motion seemed to parallel the ejection fraction. Thus the false positive cases were associated with only a minor amount of abnormal catheter motion. FIG. 2.-Systolic (A) and diastolic (B) frames from lateral cineangiogram of patient with left atrial myxoma. C, Composite line drawing of systolic (dashed lines) and diastolic (solid lines) frames. During diastole catheter moves anteriorly (arrow; cf. fig. ic); this represents paradoxical motion of catheter. CASE REPORT Case i, a 64-year-old male (AE-6o3o72), presented with a I-year history of irregular heartbeat and increasing shortness of breath. He had

3 CATHETER MOTION IN ATRIAL MYXOMA 1157 had three transient ischemic attacks in the previous year. On physical examination, the patient was in congestive heart failure with a mitral regurgitant murmur. A cardiac ultrasound examinarion was consistent with the presence of a left atrial myxoma. Right heart catheterization revealed a mean pulmonary artery wedge pressure of 17 mm. At cinean giograph y, the catheter demonstrated paradoxical motion, moving posteriorly in systole and showing localized bowing anteriorly (particularly in its lower portion) during diastole (fig. 2). During left ventriculography (and after the injection had ceased), the area of anterior bowing of the catheter demonstrated proximity to the prolapsing left atrial myxoma (fig. 3). There was moderate mitral insufficiency, and a large prolapsing left atrial myxoma was demonstrated. There was no abnormal tumor vascularity at coronary angiography. At surgery, a

4 ij58 RAUSCH ET AL. 55 g left atrial myxoma was confirmed. DISCUSSION Myxomas are the most common primary cardiac tumor; 75% occur in the left atrium. Since approximately io% of these tumors calcify, plain films may reveal calcification within the left atrium. [] Echocardiography may reveal dense echoes originating within the left atrium, which is almost pathognomonic for a left atrial myxoma [ i]. When left atrial myxoma is suggested clinically or by echocardiography, confirmatory preoperative angiography is essential. Opacification of left-side cardiac chambers after injection of contrast into the pulmonary artery usually reveals a characteristic filling defect in the left atrium. Antegrade (transeptal) catheterization for a suspected left myxoma is hazardous because of potential embolization [8]. The left atrium should therefore be visualized, preferably by pulmonary angiography [s]. However, many patients with myxoma will have an intial left ventriculogram because of the erroneous diagnosis of mitral stenosis, and the correct diagnosis may not be made in the catheterization laboratory or even later. Catheter motion analysis at this stage of the investigation process would increase the suspicion of a left atrial myxoma while the patient was still in the catheterization laboratory. With a Lehman ventriculography catheter positioned on the left ventricular floor, the normal motion of the catheter is antenor during systole and posterior during diastole. The motion usually involves the whole catheter and is not significantly affected by the inflow of blood from the left atrium during rapid filling or atrial systole. The catheter motion probably results from aortic root motion and the fact that the catheter is trapped by the aortic root. The catheter motion exactly parallels the motion of the aortic root demonstrated by echocardiography. In contrast, a prolapsing myxoma pushes a portion of the catheter forward during diastole. As the tumor returns toward the atrial cavity, the ventricular catheter moves posteriorly. This paradoxical motion was found in each of the five cases in the current report and thus provides an ancillary sign of a prolapsing mass. It must be emphasized that the ventricular catheter should be well seated on the ventricular floor. False positive anterior diastolic movement can be caused by the unseated catheter and also if the tip of the catheter is located high under the posterior mitral valve leaflet. A prolapsing atrial myxoma may produce only minimal mitral regurgitation when a left ventriculogram is performed. However, if paradoxical catheter displacement is observed at the time of catheterization, myxoma should be immediately suspected. Pulmonary angiography should be performed to confirm the diagnosis. In summary, abnormal motion of a portion of the left ventricular catheter is a useful ancillary angiographic finding in a prolapsing atrial tumor. ACKNOWLEDGMENT We express our appreciation to Mrs. Marge Billman for her assistance in preparation of the manuscript. REFERENCES I. Goldberg HP, Glenn F, Dotter CT, Steinberg I: Myxoma of the left atrium: diagnosis made during life with operative and post-mortem findings. Circulation 6: , Goodwin JF: Diagnosis of left atrial myxoma. Lancet I , Aldridge HE, Greenwood WF: Myxoma of the left atrium. BrHeart722:I89-2oo, Peters MN, Hall RJ, Cooley DA, Leachman RD, Garcia E: The clinical syndrome of atrial myxoma. 7AMA 230: , Bass NM, Sharratt GP: Left atrial myxoma diagnosed by echocardiography with observations on tumour movement. Br Heart 7 35: , I Martinez EC, Giles TD, Burch GE: Echocardiographic diagnosis of left atrial myxoma. Am 7 Cardiol 33: , Feigenbaum H, Chang S: Echocardiography. Philadelphia, Lea & Febiger, Marpole DG, Kloster FE, Bristow JD, Griswold HE: Atrial myxoma, a continuing diagnostic challenge. Am 7 Cardiol 23:597-60!, Steiner RE: Radiologic aspects of cardiac tumors. Am 7 Cardio/ 21: , 1968

5 This article has been cited by: 1. J.A Stewart, J.W Warnica, M.E Kirk, F Winsberg Left atrial myxoma: False negative echocardiographic findings in a tumor demonstrated by coronary arteriography. American Heart Journal 98:2, [CrossRef]