Letter by Barik Regarding Article, “Now You See It, Now You Don’t?”
To the Editor:
I read with interest the article, “Now You See It, Now You Don’t?” by Haroun et al.1 The authors have shared a real-time documentation wherein a part of left atrial myxoma had embolized into the brain, lower limbs, and possibly in the coronary arteries. Tumor embolization is one of the malignant presentations of cardiac myxoma which is a benign tumor. I would like to add 1 or 2 points in this context. There are 4 gray areas in the management of cardiac myxoma located in the left heart or right heart. These are as follows: (1) the lack of reliable predictors of embolism; (2) the exact time interval between the onset of diagnosis and surgical resection, although most of the series indicate early surgery is better; (3) the timing of surgery for residual myxoma after embolic episodes; and (4) anticoagulation during waiting for surgical resection. The incidence of embolism as a part of cardiac myxoma varies in different series from 9%2 to 30% to 40%3 in some other series. Approximately 25% of these cases may have cerebral embolism at the time of presentation.3,4 The literature reports that type 1 myxomas are associated with higher risk of embolization than type 2 myxomas. Although the authors have diagnosed the left atrial mass to be left atrial myxoma by 2-dimensional echocardiography, they have not mentioned the type of myxoma they saw. Transesophagial echocardiography would have given a better anatomic presentation in this case, which could have facilitated an earlier surgery. In histopathologic studies, >40% of cardiac myxomas show evidence of surface thrombi, which is an important predictor of embolism. The most common proposed mechanism of cerebral infarct is attributable to the embolization of surface thrombus over the myxoma, but the routine use of anticoagulation is not recommended. One possible reason may be that most left atrial myxomas consist of myxomatous tissue as the major component. Recently, it was reported that tumor location, macroscopic appearance, mean platelet volume, and high platelet count are strong risk factors for embolic events in patients with cardiac myxomas.5 Although most published series report that immediate surgery is necessary to avoid embolism, the authors planned surgical resection for the following week. What is the meaning of the following week? Does it mean emergency, urgency, or early surgery? The authors could have given the benefit of emergency surgical resection because the authors say “Now You See It, Now You Don’t?” The cited experience shared by the authors is not new, because acute embolic presentation is a usual feature of cardiac myxoma.
Ramachandra Barik, MD, DNB
Department of Cardiology
Nizam’s Institute of Medical Sciences
- © 2016 American Heart Association, Inc.