Myxomas are the most common primary cardiac tumors, comprising 30-50% of the total in most pathological series. More than 90% per cent of myxomas have been reported to occur sporadically.^1,2 The recurrence rate of excised myxomas is between 5% and 14%, with most recurrences at the original tumor site. Only a few cases have been reported of remote recurrence in excised myxomas. The mean age of patients with sporadic myxoma is above 50 years, and 70 per cent are females. Myxomas are rare in teenagers and are extremely uncommon in preschool children. Approximately 86 per cent of myxomas occur in the left atrium, the usual site of attachment is in the area of the fossa ovalis. Myxomas may recurr in the same or different cardiac chambers.^3,4 We report a 7 year old boy who had a right atrial myxoma resected, and who had recurrent myxoma in the left atrium.

A-7-year-old boy complaining of dyspnea and fatigue was admitted to the Cardiology Division of our hospital with a previous history of right atrial myxoma. He had been operated on 2 years prior for right atrial myxoma. The myxoma had been resected from the interatrial septum with its pedicle, and the defect had been repaired with a Dacron patch. He had no familial history of cardiac tumors.

 

On physical examination at arrival, blood pressure was 90/50 mmHg, pulse rate 115/min, and he was tachypnoeic. His liver was palpable at 6 cm below the costal margin, and his jugular venous pressure was slightly elevated. Auscultation revealed a mild systolic murmur suggestive of both mitral and tricuspid insufficiency, and a prominent pulmonary component to the second heart sound was also noted. There was evidence of ascites in the abdomen. The skin was normal.

 

Electrocardiography showed sinus tachycardia, and right ventricular hypertrophy. Chest X-ray showed minimal cardiac enlargement. Other laboratory tests were within normal limits.

 

Myxomas are very common in the left atrium. They may also occur in the right atrium, and less commonly, in the right or left ventricle. Multiple tumors may occur in the same chamber or in a combination of chambers.² Myxomas may be familial,⁴ and if so, they appear to be transmitted in an autosomal dominant manner.^1,2

 

Patients with recurrent myxoma tend to be younger than patients with sporadic myxoma.¹ Recurrence may be due to implantation of tumor cells during the first operative procedure, or regrowth from the original site due to incomplete excision. Recurrence of cardiac myxomas may be in the same chamber , and/or different chambers.

 

Although most reviews on cardiac myxomas do not report recurrence,^5-9 several reviews have commented with regard to recurrence.^1,10-21 Recurrences of myxomas are rare and contralateral recurrences are extremely rare in the literature.

 

Recurrent myxomas may be familial^4,22,23 or non-familial.^15,24 Takashi,¹⁰ Martin,¹¹ Dang,¹⁵ Aroca,²⁴ Fagan,²⁵ Fujiwara,¹⁸ and Ohshima²² have reported contralateral recurrences of cardiac myxomas. Table 1 and Table 2 summarise these reports. Martin¹¹ and Ohshima²² both reported primary right atrial myxomas that recurred in the left atrium. However, both patients were adults.

  Table 1: Sporadic recurrences of myxomas in the literature

Author	Ref.	Year	Age	Sex	Primary	Recurrence	Time interval
Jugdutt	27	1975	A		LA	LA	31 months
Dang	15	1976	A	M	LA	RV	18 months
Takashi	10	1982	27	F	LA	RA+RV+LA	4 years
Fujiwara	18	1986	A	F	LA	RA
Martin	11	1987	20	F	RA+LV	LA	4.5 years
Pavlides	19	1989	A	M	LA	LV
Fagan	25	1990	A	F	RA	RV	2 years
Ohshima	22	1990	27	F	LA	LA+RA+RV	4 years
Ohshima	22	1990	13	F	RA	LA	3 years
Miyata	26	1990	47	F	RA+LA	RA+LA	6 months
Zeybek	16	1991	22	M	LA	LA	14 years
Haught	23	1991	34	F	LA	LA
Soma	20	1992	23	F	LV	LV	10months
Aroca	24	1996	A	M	LA+RA	LA+RA*
Alami	28	1996	A		LA	LA

*Three recurrences between 1983 and 1992
 
Abbreviations

A: adult	F: female	M: male
LA: left atrium	LV: left ventricle	RA: right atrium	RV: right ventricle

 

 

Table 2: Series dealing with myxomas in the literature

Author	Reference	Year	Patients	Recurrence(s)
Gray	17	1985	14	2
McCarthy	1	1986	56	3 (1 second recurrence)
Nasser	14	1990	14	1
Tschirkov	6	1990	63	None
Loire	13	1991	85	6
Meyns	5	1993	32	None
Gotoh	8	1993	17	None
Duveau	12	1993	56	5 (4 second recurrence)
Yamamoto	7	1995	22	None
Bjessmo	29	1997	63	1
Lukacs	9	1997	50	None

 

Ohshima et al²² reported a familial cardiac myxoma with multiple and contralateral recurrence. The report described a familial recurrent cardiac myxoma involving a mother and her daughter. The mother had developed recurrent multiple myxomas at 27 years of age, four years after surgical excision of left atrial myxoma in both left and right atrium, and right ventricle. In an asymptomatic 13 year old daughter a recurrent left atrial myxoma was found three years after excision of a right atrial myxoma. Aroca et al²⁴ reported multiple recurrence of sporadic, non-familial cardiac myxoma. The patient underwent complete resection of myxoma three times within nine years.

 

Because of the possibility of recurrence, postoperative follow-up of all patients with cardiac myxoma is mandatory.²³ Besides transthoracic echocardiography, transoesophageal echocardiography may be used for both diagnosis^21,25 and follow-up²¹ of cardiac myxomas. In the last few years, recurrent of myxomas is less frequently reported, and this may be due to improvement of surgical techniques, equipment and also experience.