Left ventricular myxoma: why resection is not always enough?

Diagnostic challenges and management of left ventricular myxoma

Left ventricular myxoma (LVM) remains a rare clinical entity whose atypical presentation requires rigorous diagnostic expertise. This case report describes the management of a middle-aged female patient suffering from chest tightness and persistent exertional dyspnea for two weeks. The analysis focuses on a 61 mm x 24 mm hypoechoic mass located in the left ventricular outflow tract. This lesion, characterized by a wide implantation base on the inferior and posterior walls, specifically involves the posterior mitral leaflet, part of the chordae tendineae, and the papillary muscles.

L'objectif de cette étude est d'évaluer la performance de l'imagerie multimodale — combinant échocardiographie (ETT/ETO), IRM cardiaque et TEP/TDM — dans la caractérisation tissulaire et la planification d'une stratégie thérapeutique adaptée. L'étude teste l'hypothèse selon laquelle l'intégration de ces outils permet de distinguer efficacement cette tumeur bénigne des pathologies malignes, malgré des indices métaboliques ambigus observés en TEP/TDM au FDG. L'enjeu clinique majeur réside dans la sécurisation d'une résection complexe rendue nécessaire par la mobilité extrême de la masse vers l'orifice aortique lors de la systole.

Diagnostic approach and surgical protocol

This case report documents the management of a middle-aged female patient presenting with a two-week symptomatology (chest tightness and exertional dyspnea). The diagnostic and follow-up protocol relied on a rigorous multimodal imaging approach to characterize the intraventricular mass.

• Initial assessment: Transthoracic (TTE) and transoesophageal (TOE) echocardiography to define the morphology (irregular hypoechoic mass of 61 mm × 24 mm), its implantation base (inferior and posterior walls of the left ventricle) and its intracardiac dynamics.
• Tissue characterisation: Cardiac magnetic resonance imaging (c-MRI) to assess extension to valvular structures (posterior mitral leaflet, chordae, papillary muscles) and the degree of enhancement.
• Bilan d'extension et métabolisme : Tomographie par émission de positons couplée au scanner (TEP/TDM) au fluorodésoxyglucose (FDG) pour évaluer l'activité métabolique et exclure une étiologie maligne.
• Surgical procedure: Complete resection of the cardiac tumour associated with mitral valve replacement due to extensive involvement of the subvalvular apparatus.
• Postoperative follow-up: Clinical and ultrasound evaluation scheduled at 6 months to monitor for potential tumor recurrence.

Multimodal exploration results and clinical follow-up

The diagnostic evaluation of this middle-aged patient relied on a multimodal imaging approach, revealing an intracardiac mass with atypical characteristics due to its location and extension.

1. Cardiac imaging characterization

Transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) identified an irregular, hypoechoic mass located in the left ventricular outflow tract (LVOT). Dynamic measurements and observations are as follows:

• Dimensions: Approximately 61 mm × 24 mm.
• Implantation: Wide base fixed to the inferior and posterior walls of the left ventricle.
• Anatomical extension: Involvement of the posterior mitral leaflet, part of the chordae tendineae and papillary muscles.
• Kinetics: Extreme mobility with significant deformation; prolapse towards the aortic valve orifice in systole and return towards the left ventricular inflow tract in diastole.

Cardiac magnetic resonance imaging (CMR) confirmed the involvement of the mitral and papillary structures. The absence of significant enhancement directed the diagnosis toward a benign lesion, primarily a myxoma.

2. Metabolic evaluation and risk of malignancy

La tomographie par émission de positons (TEP/TDM) au corps entier a apporté des nuances supplémentaires :

Parameter	Observation TEP/TDM
Morphology	Fragmentary shadow, slightly hypodense, adjacent to the mitral area.
Composition	Presence of intra-lesional calcifications.
Metabolism (FDG)	Slight increase in fluorodeoxyglucose uptake.
Interpretation	Malignancy not formally excluded due to metabolic activity.

3. Surgical procedure and 6-month follow-up

Due to the unusual location, high mobility of the mass (major embolic risk), and valvular involvement, a complete surgical resection of the cardiac myxoma was performed, combined with a mitral valve replacement.

Postoperative follow-up revealed an unfavorable outcome: a tumor recurrence was detected by echocardiography during the 6-month check-up, highlighting the potential aggressiveness or the difficulty of complete resection in this complex ventricular location.

Conclusion

This case demonstrates that while left ventricular myxoma is rare, its management is complicated by the frequent involvement of the mitral subvalvular apparatus. Multimodal imaging is essential for surgical planning, although it does not guarantee the absence of recurrence.

Clinical analysis and limits

This clinical case illustrates the diagnostic complexity and surgical challenge posed by left ventricular myxomas, a rare location. Multimodal imaging was decisive: echocardiography (TTE and TOE) revealed an irregular mass measuring 61 mm x 24 mm, whose extreme mobility and systolic prolapse toward the aortic orifice presented a critical embolic risk. Cardiac MRI provided crucial specificity by detailing the attachment of the mass to the inferior and posterior walls, as well as its complex extension to the chordae tendineae and papillary muscles.

The use of PET/CT highlights, however, a diagnostic limitation: despite a metabolic evaluation, the moderate increase in FDG metabolism and the presence of calcifications did not allow for the formal exclusion of malignancy preoperatively. This uncertainty, coupled with the massive involvement of the mitral subvalvular apparatus, dictated a radical surgical strategy combining tumor resection and mitral valve replacement.

The recurrence observed only six months after the procedure is the most notable result. Although myxoma is classified as a benign tumour with a low postoperative recurrence rate in classical literature, this case demonstrates that involvement of complex valvular and subvalvular structures can favour early reappearance. For the practitioner, this report highlights that postoperative ultrasound monitoring must not be neglected, as it remains the gold standard tool for early detection of recurrence, particularly in these atypical locations where complete excision is technically demanding.

Summary of results

This report describes the management of a massive left ventricular myxoma (61 mm × 24 mm) invading the mitral subvalvular apparatus. Despite surgical excision combined with mitral valve replacement to secure margins, tumor recurrence was documented by ultrasound as early as the six-month follow-up.

In concrete terms, for the practitioner:

• Diagnostic rigor: Systematically use multimodal imaging (cardiac MRI) to precisely assess the infiltration of papillary muscles and chordae tendineae, a crucial step in anticipating the complexity of the resection.
• Postoperative monitoring: Schedule close echocardiographic follow-up starting from the first six months post-intervention; ventricular locations with a wide implantation base present a risk of early recurrence, even after complete valve replacement.

Although cardiac myxoma is the most common primary heart tumour, its location in the left ventricle remains a rare clinical phenomenon. The management of these patients requires a rigorous diagnostic strategy based on multimodal imaging, both to characterise the lesion and to assess the imminent embolic risk.

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