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|Year : 1979 | Volume
| Issue : 4 | Page : 237-238
Phantom echoes resembling a myxoma in mitral valve prolapse
AS Vengsarkar, JJ Dalal, KG Nair
Department of Cardiology, K.E.M Hospital, Parel, Bombay 400012, India
A S Vengsarkar
Department of Cardiology, K.E.M Hospital, Parel, Bombay 400012
Source of Support: None, Conflict of Interest: None
This is a case report of a patient who presented clinically with features of mitral valve prolapse. Echocardiography revealed, in addition to a systolic mitral valve prolapse, variegated shadows behind the anterior mitral leaflet characteristic of a myxoma. At surgery the prolapse of the posterior mitral leaflet was confirmed, but no myxoma was present. This case represents a rare false positive echocardiogram suggesting a myxoma in a patient with prolapsed mitral valve.
|How to cite this article:|
Vengsarkar A S, Dalal J J, Nair K G. Phantom echoes resembling a myxoma in mitral valve prolapse. J Postgrad Med 1979;25:237-8
| :: Introduction|| |
Since the first published report of an echocardiogram of left atrial myxoma by Effert and Domanig in 1959,  echocardiography has been the mainstay in the diagnosis of this tumor. So sensitive and specific is this mode of diagnosis, that angiocardiography is not considered essential prior to surgery.  At this institute there have been no false positive or false negative echocardiograms over a period of three years during which we have diagnosed five cases of myxoma  This report presents features of a case showing echocardiographic evidence of a myxoma along with mitral valve prolapse, who at surgery was found not to have a myxoma.
| :: Case report|| |
Mr. R.R,, a 40 year old farmer presented with a history of grade I dyspnoea over a period of one year. He had no history of syncope or fever. He gave no history suggestive of systemic embolization.
General examination revealed a regular pulse rate of 75/min. He was normotensive, and his jugular venous pressure was normal. Cardiovascular examination revealed the apex in the fifth left intercostal space within the mid-clavicular line. On auscultation, a non-ejection click followed by a grade 3/6 late systolic murmur was present at the apex. The alterations of the click and murmur were present at the apex and with physiological manoeuvres were characteristic of a prolapsed mitral leaflet. There was no evidence of pulmonary hypertension. His ECG and X-ray chest were within normal limits.
The echocardiogram was recorded using diagnostic Unirad Sonograph equipment with a 2.25 MHz non-focus transducer. Recordings were made on a Honeywell 1858 strip chart recorder.
On account of an emphysematous chest and a vertical heart, the mitral valve was optimally recorded at the lower left sternal edge (6th interspace). The instrument was adequately damped by appropriate adjustments of the gain and reject settings in order to exclude dispersion echoes. No abnormal echoes were recorded with a superiomedial beam orientation when the mitral valve amplitude was maximum, or within the left atrial cavity. When the beam was angulated posterolaterally to see the posterior mitral leaflet, abnormal wavy and interrupted echoes appeared during diastole (See: [Figure 1] on page 238A). The posterior mitral leaflet was in a flat neutral position (See [Figure 2]] on page 238A), and there were linear interrupted echoes suggestive of a flail posterior leaflet possibly due to ruptured chordae. The mitral leaflets showed a mid and late systolic prolapse into the left atrium (See [Figure 2] on page 238A).
Using a mid-sternal approach the patient was taken on a cardiopulmonary bypass. The posterior mitral leaflet was thickened and had a bulbous edge; the redundant leaflet was seen to prolapse within the left atrial cavity resulting in a mild mitral regurgitation. One of the chordae to the posterior leaflet was broken. There was no evidence of a myxoma. No surgical correction of the mitral valve was attempted.
| :: Discussion|| |
It is only since the advent of echocardiography that a quick, non-invasive and extremely reliable method of diagnosis of myxoma is available.  Certain other lesions mimic a myxoma at echocardiography but with care can usually be differentiated  The commonest among them is a left atrial clot, which unlike the variegated picture of a myxoma presents a homogenous appearance . 
The abnormal cloudy echoes in this case resembled in appearance the echoes recorded by us in our previous experience with left atrial myxomas.  Absence of an echo free space in early diastole in this case, is not against the diagnosis of a myxoma, as we have recorded such finding in a proven case of myxoma (See [Figure 3] on page 238A). However this case differed in respect of the site of recording of these shadows and the association of mitral valve prolapse.
Gramiak and Nanda  have reported myxoma like echoes in mitral valve prolapse. It is suggested by them, that the thickened posterior leaflet may assume an almost vertical position and is frequently folded upon itself in diastole resulting in multiple echoes. In this case the echoes were observed only when the flail posterior leaflet was recorded. It is however difficult to offer an explanation for their density and height as related to the flail posterior mitral leaflet.
There is little doubt that echocardiography is extremely valuable in the diagnosis of myxoma. In view of the mimicking pattern seen rarely in patients with prolapsed mitral valve anglocardiographic evaluation prior to surgery is advisable, in the circumstances reported herein.
| :: Acknowledgements|| |
We are thankful to Dr. C. K. Deshpande, Dean, K.E.M. Hospital for allowing us to publish this material.
Thanks are due to Dr. G. B. Parulkar and Dr. S. Bhattacharya who operated on the case.
| :: References|| |
|1.||Effort, S. and Domanig, E.: The diagnosis of intra-atrial tumors and thrombi by the ultrasonic echo method. German Med.Month., 4: 1-3, 1959. |
|2.||Feigenbaum, H.: Cardiac tumours (Chapter 16). In, "Echocardiography", 2nd Edition. Lea and Febiger, Philadelphia, 1976, pp. 447-460. |
|3.||Gramiak, R. and Nanda, N. C.: Mitral valve. "In, "Cardiac Ultrasound" (Editors: Gramiak and Waag). The C. V.Mosby Co. Ltd., Saint Louis, 1975, p. 47. |
|4.||Schattenberg, T. T.. Tajik, A. J. and Gau, G. T.: Echocardiogram in the left atrial myxoma. Chest: 63: 423-425, 1973. |
|5.||Tallury, U. K. and de Pasquale, N. P.: Ultrasound cardiography in the diagnosis of left atrial thrombus. Chest, 59: 501502, 1971. |
|6.||Vengsarkar, A. S.: Personal communication. |
[Figure 1], [Figure 2], [Figure 3]