Original Articles Korean Circulation J 1998;287:1131-1140 심장점액종의임상적고찰 :33 년간의경험분석 강웅철 1 하종원 1 장병철 2 권진욱 1 임세중 1 정남식 1 조승연 1 김성순 1 강면식 2 조상호 3 조범구 2 A Review of Cardiac Myxoma33-year Experience in a Single Institution Woong-Chol Kang, MD 1, Jong-Won Ha, MD 1, Byung-Chul Chang, MD 2, Jin-Wuk Kwon, MD 1, Se-Joong Rim, MD 1, Namsik Chung, MD 1, Seung Yun Cho, MD 1, Sung Soon Kim, MD 1, Meyun Shick Kang, MD 2, Sang-Ho Cho, MD 3 and Bum Koo Cho, MD 2 1 Cardiology Division, 2 Division of Cardiothoracic Surgery, 3 Department of Pathology, Yonsei University, College of Medicine, Seoul, Korea ABSTRACT Background and ObjectivesCardiac myxomas are uncommon. Early diagnosis and treatment are essential to reduce morbidity or mortality. Before 1970, preoperative diagnosis was difficult. With the development of echocardiography, a correct diagnosis is made before operation. We reviewed our clinical experience in diagnosis and management of 52 cases of myxomas seen over a 33-year period, 1966 to 1998. Patients and Methods There were 20 males 38% and 32 females 62%age range 780. All the patients medical records were reviewed. In twenty-five patients in whom echocardiographic features could be reviewed, clinical fetures were compared according to two distinct echocardiographic featuresround and polypoid type. ResultsEightyfour percents of the presenting symptoms were cardiac origin while systemic embolism SE accounted for 15%. Echocardiography was used most often for diagnosis. The myxomas were located in the left atrium in 50 96%, right atrium in 2 4%. One patient had multiple myxoma. The incidence of SE was significantly higher in polypoid type than in round type 58% vs 0%, p0.05. Multivariate regression analysis revealed polypoid type was the only independent predictor of SEp0.0029. Follow-up duration was ranged from 1 to 266 months. There was no deaths associated with myxoma. One patient presented with a recurrence 3 years after resection, and reoperation was performed uneventfully. ConclusionDue to the nonspecific presentation of myxoma, a high index of suspicion is needed. Surgical excision of myxoma can be considered curative with excellent longterm result. However, because of high possible occurrence of SE, a close attention should be given to those patients who have myxoma of polypoid type. Korean Circulation J 1998;287:1131-1140 KEY WORDSCardiac myxoma Systemic embolism Echocardiography Surgical excision. 서 론 1131
환자및방법 대상환자 심초음파검사 1132 Fig. 1. Incidence of cardiac myxoma. 통계분석 결과 환자의특징 Korean Circulation J 1998;287:1131-1140
가 수술후 심장 점액종으로 확진되었다. 진단 당시 환 ±35.5개월이었다(Table 1). 수술 전 증상으로는 혈로 자들의 평균연령은 47.6±16.5세였고 범위는 7세에서 차단에 의한 증상이 많아서 운동시 호흡곤란이 34례 80세까지였다. 총환자의 64%가 30세에서 60세 사이 (69%), 심계항진이 14례(27%), 기침이 16례(31%) 에 있었으며 남자가 20명(38%), 여자가 32명(62%) 있었고 Raynaud현상을 보인 경우도 1례 있었다. 종양 이었다(Table 1). 연도에 따른 발생 빈도를 보면 최근 편에 의한 색전 증상은 총 8례(15%)에서 관찰되었으며 들어 빈도가 증가하는 양상을 보였다(Fig. 1). 대부분 뇌졸중으로 7례의 환자가 실신을 경험하였거나 반신 마비 등의 증상이 있었다. 그리고 1례는 말초 동맥 임상 양상 색전증으로 색전술 시행후에 심장 점액종이 의심되어 심 대부분의 환자들이 심장과 관련된 증상을 호소하였 초음파 검사후 심장 점액종으로 진단 받았다. 우심방 점 고(84%) 증상 발현에서 진단시까지 평균기간은 17.8 액종은 2례가 있었는데 폐색전증을 의심할만한 소견은 A C B Fig. 2. Transthoracic echocardiography of round and nonprolapsing type of atrial myxoma. A. Parasternal long axis view showed a mass typical of an atrial myxoma of round type characterized by solid, round shape with nonmobile surface (indicated by arrow). There was no prolapse of a tumor into the ventricular cavity during diastole. B. Apical four chamber view showed similar findings. C. On grossly, solid, ovoid shape of myxoma with smooth surface which is similar to the echocardiographic morphology. AO denotes aorta LV, left ventricle RV, right ventricle. 1133
관찰되지 않았다. 피로감, 체중감소, 발열, 관절통 및 식 별검사로 진단 받았는데 그 중 1례는 가족성 점액종 의 욕 부진 등의 전신 증상은 대상 환자의 약 1/2에서 관찰 심하에 검사후 내분비 질환 및 피부 병변과 동반되는 복 할 수 있었다(Table 2). 4명(8%)의 환자는 증상없이 선 합 심장 점액종으로 진단 받았다. 세균성 심내막염을 보 A B C Fig. 3. Transthoracic echocardiography of polypoid and prolapsing type of atrial myxoma. A. Parasternal long axis view showed a mass typical of an atrial myxoma of polypoid type characterized by soft, irregular shape with mobile surface. B. Apical four chamber view showed the prolapse of the tumor into the ventricular cavity during diastole. C. On grossly, soft, irregular and friable shape of myxoma which is also similar to the echocardiographic images. Abbreviation as in Fig. 2. 1134 Korean Circulation J 1998;28(7):1131-1140
Table 1. Patient s population Total patients 52 Sex Male 20 38% Female 32 62% Age yrs 47.616.5 7 80 Sx duration months 17.835.5 1180 Sxsymptom, yrsyears Table 2. Preoprative symptom No of patients % Obstructive symptom Exetional dyspnea 36 69 Palpitation 14 27 Cough 16 31 Embolic symptom Cerebral artery 7 13 Peripheral artery 1 2 Systemic symptom Fatigue 26 50 Wt.loss 9 17 Fever 7 13 Arthralgia 1 2 Anorexia/nausea 9 17 Raynaud s phenomenon 1 2 Wt.weight 신체검사 점액종의위치 Table 3. Location of tumor No of patients % Lt. Atrium 50 96 Fossa ovalis 42 81 Septum lower portion 1 2 Interatrial groove 1 2 Free wall 3 6 Posterior wall 2 4 Appendage 1 2 Multiple site (septum) 1 2 Rt. Atrium 2 4 Septum 1 2 Lt.left, Rtright 검사소견 심초음파소견 1135
Table 4. ECG finding Table 5. Echocardiographic finding N25 No. of patients % Normal 14 27 LAE 15 29 LVH 5 10 RVH 10 20 Sinus tachycardia 7 13 Sinus bradycardia 1 2 Atrial fibrillation 7 13 RBBB 2 4 LAEleft atrial enlargement LVHleft ventricular hypertrophy RVHright ventricular hypertrophy RBBBright bundle branch block 수술및병리소견 No. of patients % Round 13 52 Polypoid 12 48 Prolapsing 17 69 Non prolapsing 8 32 Calcification 6 24 Necrotic lesion 3 12 N35 LVEDD 54 mm 6 17 LAD 44 mm 19 54 LVEF 54% 6 17 Pericardial effusion 3 9 LVEDDleft ventricular end diastolic diameter LADleft atrial diameter LVEFleft ventricular ejection fraction 종양의형태에따른색전증의빈도및임상양상의차이 장기추적관찰결과 1136 Korean Circulation J 1998;287:1131-1140
Table 6. Morphological classification 고 환자의특징및종양의위치 Round Polypoid p No. of patients 13 12 찰 n25 Sex M/F 4/9 7/5 NS Age yrs 61.510.1 48.813.0 p.011 Sx. duration mon 26.456.4 11.316.5 NS Location L/R 11/1 11/0 NS P/NP 6/7 11/1 p.030 Embolism % 0 58 p.002 Size cm 5.7 2.2 6.2 2.4 NS yrsyears, monmonths, Lleft, Rright, Pprolapsing NPnonprolapsing, NSnot significant Table 7. Risk factor of embolism No. of patients Embolism Embolism n25 Sex M/F 2/5 6/12 NS Age yrs 46.316.5 58.99.9 NS Round/Polypoid 0/7 13/5 p.0029 P/NP 6/1 11/7 NS Size cm 5.8 2.9 6.2 2.0 NS yrsyears, Pprolapsing, NPnonprolapsing NSnot significant p 임상양상및심초음파소견 1137
비전형적심장점액종 1138 심장점액종의재발 진단 Korean Circulation J 1998;287:1131-1140
치료 장기추적관찰 연구배경 : 요약 방법 : 1139
결과 : 결론 : 1140 중심단어 REFERENCES 1) Castells E, Ferran V, Calbert JM, et al. Cardiac myxomas Surgical treatment and recurrence. J Cardiovascular Surg 199031suppl.46. Abstract. 2) Miralles A, Bracamonte L, Soncul H. Cardiac tumors Clinical experience and surgical results in 74 patients. Ann Thorac Surg 199152886-95. 3) Kirkeby K, Leren P. Myxoma of the heart Polypoid tumor of the left atrium diagnosed antemortem. Acta Med Scandinav 1953143385-91. 4) Crafoord C. Discussion on late results of mitral commissurotomy. In Lam CR, editor. International Symposium on Cardiovascular Surgery. Philadelphia WB Saunders1955. p.202-11. 5) O, Neil MB, Grahl TM, Hurey EJ. Cardiac myxoma A clinical diagnosis challenge. Am J Surg 1979138:68-76. 6) Heydorn WH, Gamez AC, Kleid JJ. Atrial myxoma in siblings. J Thorac Cardiovasc Surg 197365484-6. 7) Greenwood WF. Profile of atrial myxoma. Am J Cardiol 196821367-75. 8) Gerbode FG, Kerth WJ, Hill JD. Surgical management of tumors of the heart. Surgery 19676194-101. 9) Hubbard TF, Neil RN. Myxoma of the right ventricle: Report of a case with unusual findings. Am Heart J 1971;81:548-53. 10) Krause S, Adler LN, Peddy PS, Magovern GJ. Intracardiac myxoma in siblings. Chest 197160404-6. 11) McAllister HA Jr. Primary tumors and cysts of the heart and pericardium. Curr Probl Cardiol 197948-51. 12) Goodwin JF. Diagnosis of left atrial myxoma. Lancet 1963 1464-7. 13) Nasser WK, Davis RH, Dillon JC, Taver ME, Halmen CH, Feigenbaum H, Fish C. Atrial myxoma. Phonocardiographic, Echocardiographic, Hemodynamic and Angiographic features in nine cases. Am Heart J 197283810-24. 14) Attar S, Lee Y, Singleton R, Scherlis L, David R, McL-aughlin JS. Cardiac myxoma. Ann Thorac Surg 198029397-405. 15) Desausa AL, Muller J, Campbell R, Batnisky S, Rankin L. Atrial myxoma A review of neurological complication, metastasis and recurrence. J Neurol Neurosurg Psychiatry 1978411119-24. 16) Yukinori M, Hideaki S, Shinji S, Hitoshi T, Akira T. The Surgical Treatment Of 30 Patients with Cardiac Myxomas A Comparision of Clinical Features According to Morphological Classification. Surgery Today 199424596-8. 17) Takatsugu S, Shigeyuki M, Yuo K, Toshihiko K, Isao Y. Left atrial myxoma Using gross anatomic tumor types to determine clinical features and coronary angiographic findings. Chest 1995107674-9. 18) Tsugiyasu K, Shigeru U, Atsushi S, Yoichi N, Yasuo M, Susumu I, et al. Interleukin-6 and cardiac myxoma. Am J Cardiol 199474965-7. 19) Silverman NA. Primary cardiac tumors. Ann Surg 1980 191127-38. 20) Powers JC, Falkoff M, Henlnle RA. Familial cardiac myxoma Emphasis on unusual clinical manifestations. J Thorac Cardiovasc Surg 197977782-8. 21) McCarthy DM, Piehler JM, Schaff HV. The significance of multiple, recurrent and complex cardiac myxomas. J Thorac Cardiovasc Surgery 198691389-96. 22) Carney JA. Carney complex The complex of myxomas, spotty pigmentation, endocrine overactivity, and schwanomas. Seminars in Dermatology1995. p.90-3. 23) Dein JR, First WH, Stinson EB. Primary cardiac neoplasmearly and late results of surgical treatment in 42 patients. J Thorac Cardiovasc Surg 198793502-11. 24) Hanson EC, Gill CC, Razavi M. The surgical treatment of atrial myxomas. J Thorac Cardiovasc Surg 198589298-303. 25) Shyamal Premaratne, Nahidh W, Hasaniya, Henry Y. Atrial Myxoma Experiences with 35 patients in Hawaii. Am J Surg 1995169600-3. Korean Circulation J 1998;287:1131-1140