A Murmur of a Tumor
A 67-year-old woman presented with edema of the lower extremities. Her blood pressure was 130/90 mm Hg, and her pulse was 80 bpm and regular. A grade II/VI, low-pitched diastolic rumble was heard along the left sternal border, which intensified before the first heart sound (online-only Data Supplement Audio File I). This diastolic murmur led us to promptly perform 2-dimensional echocardiography, which revealed a mobile, inhomogeneously hyperechoic mass in the right atrium (Figure 1; online-only Data Supplement Movie). The tumor was attached to the right atrial free wall and prolapsed into the right ventricle during diastole. Doppler flow signals showed a sudden decrease in tricuspid flow at the moment when the tumor was protruded into the valve in early diastole (Figure 2, arrows). ECG-gated, contrast-enhanced, computed tomographic scans demonstrated a tumor 65 mm in diameter that was attached to the inferior wall of the right atrium and a feeding vessel that arose from the inferior phrenic artery (Figure 3). The tumor was removed surgically and was diagnosed as myxoma on histological examination. The postoperative course was uneventful. The patient’s leg edema disappeared soon after the surgery, and the diastolic rumble was no longer audible (online-only Data Supplement Audio File II). Doppler echocardiography showed decreased tricuspid diastolic flow velocities without notch-like flow deficits (Figure 4, arrows).
In general, a systolic heart murmur does not necessarily indicate the presence of heart disease, whereas a diastolic murmur is almost always abnormal. A diastolic rumble is pathognomonic for atrioventricular valve stenosis. An augmented rumble intensity during late diastole is attributed to an increase in transvalvular flow after atrial contraction, known as “presystolic accentuation.” Diastolic rumble is rarely encountered in developed countries, along with a decline in the prevalence of rheumatic heart disease, and cardiac myxoma is an important differential diagnosis.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.109.869453/DC1.