Year : 2014  |  Volume : 17  |  Issue : 4  |  Page : 306--308

Intraoperative transesophageal echocardiography assessment of right atrial myxoma resulting in a change of the surgical plan

Sathish Kumar Dharmalingam, Raj Sahajanandan 
 Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India

Correspondence Address:
Sathish Kumar Dharmalingam
Department of Anaesthesia, Christian Medical College, Vellore 632 004, Tamil Nadu


Transesophageal echocardiography (TEE) is an important diagnostic tool. It provides structural and functional assessment of cardiac structures which can improve the overall outcome of the patient. We present a case with right atrial myxoma in which TEE helped to find the attachment of the mass so that overall surgical plan was changed.

How to cite this article:
Dharmalingam SK, Sahajanandan R. Intraoperative transesophageal echocardiography assessment of right atrial myxoma resulting in a change of the surgical plan.Ann Card Anaesth 2014;17:306-308

How to cite this URL:
Dharmalingam SK, Sahajanandan R. Intraoperative transesophageal echocardiography assessment of right atrial myxoma resulting in a change of the surgical plan. Ann Card Anaesth [serial online] 2014 [cited 2020 Jun 3 ];17:306-308
Available from:

Full Text


Myxoma comprises 70% of the adult intracardiac primary benign tumors. [1] Most of them arise from the left atrium (75-80%), followed by right atrium (15-20%) and both ventricles (5%). [2] Both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are an important tool to diagnose these tumors. [3] TEE seems to be superior to TTE as an initial screening procedure for cardiac tumors. [4]


A 43-year-old, previously healthy gentleman, presented with a history of dyspnea on exertion (NYHA class II) since past 3 years. Physical examination of the patient revealed no abnormalities. Preoperative TTE showed a large right atrial mass protruding into the right ventricle with the stalk attached to the interatrial septum and mild tricuspid regurgitation. No atrial septal defect (ASD) was found. He was posted for excision of the right atrial myxoma under cardiopulmonary bypass (CPB). Anesthesia was induced with titrated doses of midazolam, fentanyl, and sevoflurane; rocuronium was administered to facilitate endotracheal intubation with 8.0 mm cuffed oral endotracheal tube. Monitors used were electrocardiogram, pulse oximetry, end-tidal CO 2 , arterial blood pressure, nasopharyngeal temperature, and central venous pressure. There were no significant hemodynamic disturbances during induction of anesthesia. We performed the intra-operative TEE in different views including mid-esophageal (ME) four-chamber, ME right ventricular inflow-outflow, ME bicaval, and modified ME bicaval to confirm the attachment and the extent of the myxoma. TEE revealed a pedunculated mass arising from the anterolateral wall of the right atrium [Figure 1] protruding into the right ventricle during diastole [Figure 2] but the interatrial septum was free and intact. This led to a change in the surgical plan to remove the tumor without arresting the heart. Briefly, high superior vena cava cannulation to prevent tumor dislodgement and inferior vena cava cannulation were performed. Snaring of these veins and other manipulations near the right atrium was done gently and carefully in order to avoid the embolization of the tumor. In addition, before initiation of CPB, the interatrial septum was examined again to rule out any ASD or persistent foramen ovale, and it was ruled out.{Figure 1}{Figure 2}

After opening the right atrium, a gelatinous multiloculated tumor was seen occupying the whole of the right atrium, and the pedicle was attached to the superior aspect of cristae terminalis below the junction of superior venacava and right atrium. The entire tumor was excised without damage to the tricuspid valve and precaution was taken during excision of the tumor to prevent any stretching or distortion of the tricuspid valve and the annulus. Adequate function of the tricuspid valve was confirmed by TEE [Figure 3] after separation of the patient from CPB. Patient had an uneventful postoperative period. The histopathological study of the tumor confirmed the diagnosis of myxoma.{Figure 3}


In our case, though preoperative TTE localized the tumor arising from the right atrium and its dimension, it failed to give information regarding the attachment of tumor. Intraoperative TEE delineated the precise attachment of the tumor mass to the right atrium which led to change of the surgical plan to remove the tumor without arresting the heart. Evidently, TEE can provide useful information for medical management and surgical intervention of intracardiac tumors. [5]

Right atrial myxoma usually arises from the fossa ovalis or base of the interatrial septum. [6] Very rarely, it arises from Eustachian valve near inferior vena cava or the free wall of the right atrium. [7],[8] In our patient, the tumor was very large and originated from cristae terminalis, the free wall of the right atrium. Because of large size, the preoperative TTE failed to localize the precise attachment of the tumor. But with TEE, we were able to describe the tumor and its attachment with higher accuracy, which was confirmed after opening the right atrium.To summarize, this case highlights the importance of intraoperative TEE to identify the morphological characteristics of cardiac masses.


1Sheppard MN, Mohiaddin R. Tumors of the heart. Future Cardiol 2010;6:181-93.
2Mittle S, Makaryus AN, Boutis L, Hartman A, Rosman D, Kort S. Right-sided Myxomas. J Am Soc Echocardiogr 2005;18:695.
3Ha JW, Kang WC, Chung N, Chang BC, Rim SJ, Kwon JW, et al. Echocardiographic and morphologic characteristics of left atrial myxoma and their relation to systemic embolism. Am J Cardiol 1999;83:1579-82, A8.
4Mügge A, Daniel WG, Haverich A, Lichtlen PR. Diagnosis of noninfective cardiac mass lesions by two-dimensional echocardiography. Comparison of the transthoracic and transesophageal approaches. Circulation 1991;83:70-8.
5DeVille JB, Corley D, Jin BS, de Castro CM, Hall RJ, Wilansky S. Assessment of intracardiac masses by transesophageal echocardiography. Tex Heart Inst J 1995;22:134-7.
6Chitwood WR Jr. Cardiac neoplasms: Current diagnosis, pathology, and therapy. J Card Surg 1988;3:119-54.
7Teoh KH, Mulji A, Tomlinson CW, Lobo FV. Right atrial myxoma originating from the eustachian valve. Can J Cardiol 1993;9:441-3.
8Sajja LR, Mannam G, Penumatcha KP, Sompalli S, Angajala R. Right atrial myxoma arising from crista terminalis in septuagenarian. Asian Cardiovasc Thorac Ann 2001;9:322-4.