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Left atrial myxoma: magnet or echo?

A 78-year-old woman was referred for elective transthoracic echocardiography (TTE) after she had presented to a peripheral hospital with a self-limited episode of atrial fibrillation. She had been in previous good health, but had undergone a complete excision of a colon cancer 2 years earlier. There was no evidence of tumour recurrence on follow-up colonoscopies to date. The TTE identified a left atrial mass and therefore she was referred for further investigation and management to our institution. She described exertional dyspnoea for several months (New York Heart Association class II) but no syncope or symptoms of thromboembolic events. Several further investigations were performed to help define the left atrial mass, which was suspected to be a left atrial myxoma, including repeat TTE (Fig. 1a), trans-oesophageal echocardiography (TOE) (Fig. 1b) and cardiac magnetic resonance imaging (MRI). The cardiac MRI included fat suppressed black blood T1 (Fig. 1c) and T2 (Fig. 1d) weighted imaging, as well as steady state precession and spoiled gradient echo cines (not shown). This case highlights the utility of cardiac MRI for noninvasively identifying and characterising cardiac masses. Cardiac MRI allows accurate assessment of the insertion of the mass into the atrial septum and shows heterogeneous signal intensity, both features characteristic of atrial myxoma, and therefore provides information not always provided by TTE.1,2 Although TTE is relatively sensitive at identifying atrial myxomas, it is not always able to differentiate such masses from left atrial thrombus.3 Cardiac MRI allows high-resolution imaging of cardiac structure and function, as well as a multitude of other assessments including stress perfusion and wall motion imaging, blood flow estimation, and noninvasive coronary imaging.4 It should be considered an excellent adjunct to current imaging modalities in diagnosis of cardiac masses.1 Cardiac MRI may exclude the need for TOE in those patients requiring further evaluation of atrial myxoma before referral for surgery.