Here's a story - A farmer in his early 70ies came to our hospital. His physician was searching for a source of embolism following a couple of minor strokes. The patient had a history of hypertension and the ECG showed atrial fibrillation. On transthoracic echo we suspected a small mass in the left atrium (Image 1). We performed a TEE study, which confirmed the suspicion. Both 2D and 3D TEE of the mass showed that it was about the size of a pea, clearly attached to the interatrial septum with a stalk, was rather mobile and had a cauliflower appearance. The left atrium was enlarged, otherwise no abnormalities were found. In particular, there were no thrombi in the left atrium.
Take a look...
So what do you think of the mass? Well, we thought it was a small atrial myxoma. Myxomas are the most common benign tumors of the heart. The overall incidence is about 1:500. They can resemble a mushroom and have a more solid and immobile structure, or (as in our case) be of the lobulated cauliflower type. The latter have a higher likelihood for embolization. Myxomas are most frequently found in the left atrium attached to the interatrial septum by a stalk. So all of these features fit pretty well to the findings in our patient. So what's next? Well, the general recommendation would be to remove the mass as soon as possible (remember: he experienced a few minor strokes already). But the farmer refused any kind of operation. And, to be honest there was also one other thing that needed clarification: the patient also had atrial fibrillation and we could not exclude that the mass was actually a thrombus. Despite the fact that most left atrial thrombi are found in the left atrial appendage (80%) and not in the left atrium itself, we had to give the patient one more chance and see if anticoagulation affected the mass.
Well, unfortunately it didn't. Repeat echo after four weeks showed exactly the same mass (Image 4).
Now it was time for surgery but again, the patient refused any form of operation. Who can blame a farmer who kept away from doctors over 70 years? And what happened to him? As far as we know, he lives a life of gardening with a cauliflower in his chest and has had no further embolic events. Possibly anticoagulation alone did the job. After all, thrombi can also attach to the myxoma – so the source of the embolism might have in fact been a thrombus. A thrombus that we failed to detect or which was already gone at the time of TEE.
In all imaging modalities we tend to borrow words from every-day-life and in particular agriculture to describe structures and masses. This is a perfect way to describe their sizes, shape and surface. After all, vegetables and fruits look quite similar all over the world. Unless you are a farmer in Alaska who holds the record for the largest cauliflower (31.25 lbs or 14.1 kg)!
Stay tuned for more cases to come,
Yours Tommy Binder and the 123sonography team
PS.: We would love to hear your feedback and comments below.