Abstract
Cardiac myxomas are the most common primary cardiac tumours. The overall prevalence is very low and up to 25% present asymptomatically. In Asia, the data on myxomas is limited. Therefore, we aimed to outline a multi-ethnic Asian population of cardiac myxoma patients. We included all index echocardiographic diagnoses of myxoma at a tertiary cardiovascular referral centre from May 2004 to April 2021. A retrospective review of all patients’ medical records was conducted. Data including patient characteristics, clinical presentation, imaging, treatment, and outcomes were collected and analysed. A total of 64 patients (mean age 66.4 years old, male 61%) were diagnosed with cardiac myxoma. The incidence of major adverse cardiovascular events (MACE) was 10 (16.1%) and 10-year mortality was 11 (17.2%). The proportion of asymptomatic patients (30.2%) increased from 15.4% before 2012 to 35.3% after 2012. Pre-existing chronic kidney disease and ischaemic heart disease were independently associated with increased risk of mortality and MACE (p-values < 0.05). Most patients (75.0%) underwent surgical resection. This was associated with a decreased risk of mortality and MACE (p-values < 0.05). The increase in the diagnosis of asymptomatic patients over the years could be attributed to increased opportunistic screening and incidental pickups. Surgical resection was associated with better outcomes. However, the poor outcomes of non-operated patients may be due to the concurrent comorbidities that preclude surgery.
Supplementary Information
The online version contains supplementary material available at 10.1038/s41598-025-20863-4.
Keywords: Asymptomatic, Cardiac myxoma, Cardiac surgery, Clinical characteristics, Major adverse cardiovascular events, Mortality
Subject terms: Cardiology, Diseases, Signs and symptoms
Introduction
Cardiac myxomas are the most common benign primary cardiac tumours. The majority of cardiac myxomas originate in the left atrium, followed by the right atrium, cardiac valves, ventricles, and multiple sites1. The classic triad of the presentation of cardiac myxomas includes: (i) obstructive symptoms (such as chest pain, dyspnoea and syncope), (ii) embolic complications (in particular, stroke and myocardial infarction) and (iii) systemic symptoms (including fever, fatigue and loss of weight)2–4. Rarely, cardiac myxomas can also be familial, as part of genetic syndromes such as Carney’s Syndrome2,5,6. However, up to 25% of cardiac myxomas can also present asymptomatically, with this trend increasing over the past decade3.
Despite their rarity7, it remains important for cardiac myxomas to be picked up early, given the potential life-threatening embolic complications of myocardial infarction8 and sudden cardiac death9. It is often deemed reasonable to investigate using a transthoracic echocardiogram to exclude myxoma as a possible cause of embolism, especially in the presence of other symptoms that may be indicative8. However, given how cardiac myxomas may present similarly to other cardiovascular diseases or be entirely asymptomatic, early diagnosis and treatment remain highly challenging. This issue is compounded in Asia, where data on the subject is very limited – the majority of which have very small sample sizes10,11. As such, it is important to understand presentations of cardiac myxomas in a multiethnic Asian context.
The objective of this study was to describe and outline a population of patients with cardiac myxomas in a multi-ethnic Asian population, providing insights into their clinical presentations and outcomes. These findings may then contribute to earlier diagnosis and improved management strategies for better outcomes for these patients.
Methods
Participant recruitment and data collection
This study reviewed all patients with index echocardiographic diagnoses of cardiac myxomas at the National University Heart Centre Singapore, a tertiary cardiovascular referral centre from May 2004 to April 2021. The study was approved by the local institutional review board (Domain Specific Review Board-C, National Healthcare Group, Study number 2021/00623). The requirement for informed consent was waived by the National Healthcare Group Domain Specific Review Board as the patient data had been deidentified prior to inclusion in the study. All research was performed in accordance with the declaration of Helsinki. All consecutive cases of cardiac myxoma diagnosed on transthoracic echocardiogram were included. Medical records were reviewed retrospectively. Data including patient characteristics, clinical presentation, diagnostic results, surgical treatment and patient outcomes were collected and analysed.
Statistical analysis
All continuous variables are presented as mean ± S.D. unless otherwise specified. All categorical variables are presented as n (%) unless otherwise specified. Differences in baseline and clinical characteristics between patients with cardiac myxoma who died and did not die at the end of the data collection on 4 November 2022 were evaluated using the Chi-square test for categorical variables and the T-test for continuous variables. The median follow-up duration was derived using the reverse Kaplan-Meier estimator. Time to mortality data for the overall population were graphically represented via the Kaplan-Meier method. We also sought to characterise the incidence of major adverse cardiovascular events (MACE) within our population. MACE was defined as the presence of cardiovascular death, acute myocardial infarction (AMI), stroke or congestive cardiac failure12. We conducted 2 univariate logistic regression analyses with death and MACE as the outcomes, using Firth’s logistic regression. Further multivariate logistic regression was then conducted on the significant variables of the death and MACE outcomes. The 10-year survival rates of cardiac myxoma patients were also stratified based on significant predictors of death. Continuous variables were standardised prior to the logistic regression. Statistical analysis was performed using R statistical software Version 4.3.3 (R Core Team, 2022), with statistical significance set at p-value < 0.05.
Results
Clinical characteristics of the participants
A total of 64 patients were included in our study. They were all diagnosed with cardiac myxomas via a transthoracic echocardiogram (TTE). The mean age of the participants was 66.4±15.6 years old, with 61% being males and a mean body mass index of 24.4±6.0 kg/m2. The ethnicities of the participants were Chinese (70.3%), Malay (14.1%), Indian (4.7%), and others (10.9%). There was no significant difference in age of diagnoses, sex, or ethnicity between those who died and those who did not die (Table 1). Deceased patients were more likely to have a history of chronic kidney disease (CKD), ischaemic heart disease (IHD) or diabetes mellitus (DM). Mortality was more common amongst patients who developed congestive cardiac failure or acute myocardial infarction. Throughout the follow-up period, there was no recurrence of cardiac myxoma reported.
Table 1.
Summary of the clinical characteristics of the participants including demographics and concomitant medical conditions.
| Population Demographics | No. Of participants (%) | p-value | ||
|---|---|---|---|---|
| Overall (n = 64) |
Survived (n = 53) |
Deceased (n = 11) |
||
| Age (years) | 66.4 ± 15.6 | 65.6 ± 14.9 | 70.6 ± 18.8 | 0.33 |
| Age at diagnosis (years) | 61.0 ± 16.0 | 59.5 ± 15.1 | 69.0 ± 19.2 | 0.09 |
| Smoker | 12 (18.8) | 10 (18.9) | 2 (18.2) | 1.0 |
| Male Gender | 39 (60.9) | 30 (56.6) | 9 (81.8) | 0.22 |
| Ethnicity | 0.08 | |||
| Chinese | 45 (70.3) | 37 (69.8) | 8 (72.7) | |
| Malay | 9 (14.1) | 8 (15.1) | 1 (9.1) | |
| Indian | 3 (4.7) | 1 (1.9) | 2 (18.2) | |
| Others | 7 (10.9) | 7 (13.2) | 0 (0.0) | |
| Body Mass Index (kg/m2) | 24.4 ± 6.0 | 24.6 ± 6.0 | 23.4 ± 5.8 | 0.58 |
| Concomitant Medical Conditions | ||||
| Cardiovascular Risk Factors | ||||
| Hypertension | 29 (45.3) | 22 (41.5) | 7 (63.6) | 0.31 |
| Hyperlipidaemia | 25 (39.1) | 18 (34.0) | 7 (63.6) | 0.14 |
| Diabetes Mellitus | 11 (17.2) | 6 (11.3) | 5 (45.5) | 0.02 |
| Peripheral Vascular Disease | 1 (1.6, n = 63) | 0 (0.0, n = 52) | 1 (9.1) | 0.39 |
| Cardiac | ||||
| Ischaemic Heart Disease | 7 (10.9) | 2 (3.8) | 5 (45.5) | < 0.001 |
| Atrial Fibrillation | 2 (3.1) | 1 (1.9) | 1 (9.1) | 0.77 |
| Congestive Cardiac Failure | 1 (1.6) | 0 (0.0) | 1 (9.1) | 0.38 |
| Others | ||||
| Stroke/Transient Ischaemic Attack | 11 (17.2) | 10 (18.9) | 1 (9.1) | 0.73 |
| Hemiplegic | 1 (1.6) | 1 (1.9) | 0 (0.0) | 1.0 |
| Chronic Kidney Disease | 7 (10.9) | 1 (1.9) | 6 (54.5) | < 0.001 |
| Chronic Obstructive Pulmonary Disease | 2 (3.1) | 2 (3.8) | 0 (0.0) | 1.0 |
| Malignancy | 4 (6.2) | 3 (5.7) | 1 (9.1) | 1.0 |
| Dementia | 1 (1.6) | 1 (1.9) | 0 (0.0) | 1.0 |
| Connective Tissue Disease | 2 (3.1) | 1 (1.9) | 1 (9.1) | 0.77 |
| Outcomes | ||||
| Deaths | 11 (17.2) | - | - | - |
| Major Adverse Cardiovascular Events (MACE) | 10 (16.1, n = 62) | 3 (5.7) | 7 (77.8) | < 0.001 |
| Cardiovascular Death | 5 (7.8) | 0 (0.0) | 5 (45.5) | < 0.001 |
| Congestive Cardiac Failure | 4 (6.5, n = 62) | 1 (1.9) | 3 (33.3, n = 9) | 0.005 |
| Stroke | 3 (4.8, n = 62) | 1 (1.9) | 2 (22.2, n = 9) | 0.07 |
| Acute Myocardial Infarction | 4 (6.5, n = 62) | 1 (1.9) | 3 (33.3, n = 9) | 0.005 |
Presenting complaints
The presenting complaints of the participants are presented in Table 2. Most patients were symptomatic at the time of diagnosis (40/61, 65.6%). The proportion of asymptomatic patients diagnosed with cardiac myxoma increased from 15.4% before 2012 to 35.3% after 2012. There was a gradual increase in the diagnosis of cardiac myxoma in asymptomatic patients from 2005 to 2021 (Fig. 1). The mean age of diagnosis before 2012 was 57.2 ± 17.0 years, while the mean age of diagnosis after 2012 was 62.0 ± 15.8 years (p-value = 0.367). The mean age of asymptomatic patients was 63.4 years, while that of symptomatic patients was 57.1 years (p-value = 0.181). Out of the triad of cardiac myxoma presentation, obstructive symptoms were the most common (25/40, 62.5%), followed by embolic symptoms (12/40, 30.0%) and systemic symptoms (4/40, 10.0%). Deceased patients were more likely to present with fatigue (Table 2).
Table 2.
Summary of presenting complaints of participants sorted based on obstructive, systemic and embolic symptoms.
| Presenting Complaints | No. Of participants (%) | p-value | ||
|---|---|---|---|---|
| Overall (n = 61) |
Survived (n = 52) |
Deceased (n = 9) |
||
| Asymptomatic | 20 (30.2. n = 60) | 17 (33.3, n = 51) | 3 (33.3, n = 9) | 1.0 |
| Symptomatic | 40 (65.6) | 32 (61.5) | 8 (88.9) | 0.23 |
| Obstructive Symptoms | 25 (41.0) | 19 (36.5) | 6 (66.7) | 0.18 |
| Dyspnoea | 15 (24.6) | 11 (21.2) | 4 (44.4) | 0.28 |
| Chest Pain | 7 (11.5) | 6 (11.5) | 1 (11.1) | 1.0 |
| Syncope | 6 (9.8) | 5 (9.6) | 1 (11.1) | 1.0 |
| Heart Failure Symptoms | 3 (4.9) | 2 (3.8) | 1 (9.1) | 0.92 |
| Systemic Symptoms | 4 (6.7, n = 60) | 2 (3.9) | 2 (22.2) | 0.19 |
| Fever | 3 (4.9) | 2 (3.8) | 1 (11.1) | 0.92 |
| Fatigue | 2 (3.3, n = 60) | 0 (0.0, n = 51) | 2 (22.2) | 0.02 |
| Loss of Weight | 1 (1.6) | 0 (0.0) | 1 (11.1) | 0.32 |
| Embolic Symptoms | ||||
| Stroke Symptoms | 13 (21.3) | 12 (23.1) | 1 (11.1) | 0.71 |
| Signs | ||||
| Mid Diastolic Murmur | 1 (1.6) | 1 (1.9) | 0 (0.0) | 1.0 |
Fig. 1.
Proportion of asymptomatic cardiac myxoma patients from the years 2005 to 2021.
Imaging findings
For diagnosis of the cardiac myxoma, all the participants underwent a transthoracic echocardiogram. Table 3 summarises the details noted in the echocardiogram concerning the cardiac chamber origin and septal involvement of the cardiac myxoma. The left atrium (53/64, 82.8%) was more commonly involved than the right atrium (8/64, 15.7%). One participant had multiple chamber involvement. Septal involvement (43/51, 84.3%) was more commonly noted than extra-septal involvement. There was a significant difference in the cardiac chamber involved between the deceased patients and the survivors (Table 3). Right atrial involvement of cardiac myxoma was more prevalent in CKD patients (40.0%) than in non-CKD patients (3.8%). Right atrial involvement of cardiac myxoma was also more prevalent in IHD patients (30.0%) than in non-IHD patients (7.5%).
Table 3.
Summary of the imaging findings of cardiac Myxoma based on chamber and septal involvement.
| Imaging Findings | No. of participants (%) | p-value | ||
|---|---|---|---|---|
| Overall, n = 64 | Survived, n = 53 | Deceased, n = 11 | ||
| Cardiac Chamber Involvement | 0.04 | |||
| Left Atrium | 53 (82.8) | 46 (86.8) | 7 (63.6) | |
| Right Atrium | 8 (15.7) | 7 (13.2) | 3 (27.3) | |
| Multiple chambers | 1 (1.6) | 0 (0.0) | 1 (9.1) | |
| Septal Involvement | n = 51 | n = 43 | n = 8 | 0.80 |
| Septal | 43 (84.3) | 37 (86.0) | 6 (75.0) | |
| Extra-septal | 8 (15.7) | 6 (14.0) | 2 (25.0) | |
Management
The management of cardiac myxomas can be split into 2 main groups – medical and surgical. Medical therapies aim to manage the complications that may arise from cardiac myxomas, such as congestive cardiac failure and cardiac arrhythmia13. Table 4 presents the intervention characteristics of cardiac myxoma patients by their survival status. Patients who died (p-value < 0.001) were more likely to have been prescribed angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB). Prescription of ACEi/ARBs was significantly more common (p-value = 0.04) in CKD patients (57.1%) than in non-CKD patients (15.8%). In addition, most patients (75.0%) underwent surgical resection. Surgical intervention was associated with decreased mortality (p-value = 0.004). No other interventions were associated with any differences in mortality (p-value > 0.05).
Table 4.
Summary of management of cardiac Myxoma participants according to medication and surgical intervention. ACEi/ARB refers to angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and MRA refers to mineralocorticoid receptor antagonists.
| Management | No. Of participants (%) | p-value | ||
|---|---|---|---|---|
| Overall (n = 64) | Survived (n = 53) | Deceased (n = 11) | ||
| Medication Prescribed | 50 (78.1) | 40 (75.5) | 10 (90.9) | 0.47 |
| Antiplatelet | 28 (43.8) | 20 (37.7) | 8 (72.7) | 0.07 |
| Anticoagulant | 16 (25.0) | 14 (26.4) | 2 (18.2) | 0.85 |
| Warfarin | 11 (17.2) | 10 (18.9) | 1 (9.1) | 0.73 |
| Direct Oral Anticoagulant | 5 (7.8) | 4 (7.5) | 1 (9.1) | 1.0 |
| Beta Blockers | 26 (40.6) | 20 (37.7) | 6 (54.5) | 0.49 |
| Calcium Channel Blocker | 9 (14.1) | 8 (15.1) | 1 (9.1) | 0.96 |
| Statins | 36 (56.2) | 30 (56.6) | 6 (54.5) | 1.0 |
| ACEi/ARB | 13 (20.3) | 6 (11.1) | 7 (63.6) | < 0.001 |
| MRA | 3 (4.7) | 3 (5.7) | 0 (0.0) | 0.98 |
| Diuretics | 11 (17.2) | 7 (13.2) | 4 (36.4) | 0.16 |
| Surgical Intervention | 48 (75.0) | 44 (83.0) | 4 (36.4) | 0.004 |
Predictors of mortality
Pre-existing CKD (p-value < 0.001), DM (p-value = 0.01) and IHD (p-value = 0.001) were independently associated with increased mortality of myxoma patients (Table 5). Surgical intervention was associated with decreased mortality rates (p-value = 0.002). Age, sex, ethnicity, pre-existing hypertension and hyperlipidaemia were not associated with any differences in mortality rates (p-value > 0.05). Pre-existing CKD was the only patient characteristic associated with increased mortality outcomes after multivariate regression of all significant variables (p-value = 0.01, Table 5).
Table 5.
Logistic regression between mortality and patient characteristics.
| Characteristics | Univariate Odds Ratio (95% CI) | p-value | Multivariate Odds Ratio (95% CI) | p-value |
|---|---|---|---|---|
| Age | 1.37 (0.718, 2.84) | 0.35 | - | - |
| Male Sex | 2.93 (0.738, 16.4) | 0.13 | - | - |
| Chinese | 1 (ref) | - | - | - |
| Malay | 0.779 (0.0757, 4.25) | 0.79 | - | - |
| Indian | 7.35 (0.868, 88.5) | 0.07 | - | - |
| Other Ethnicity | 0.294 (0.00219, 2.86) | 0.35 | - | - |
| Hypertension | 2.33 (0.659, 9.14) | 0.19 | - | - |
| Hyperlipidaemia | 3.2 (0.897, 12.6) | 0.07 | - | - |
| Chronic Kidney Disease | 41.4 (6.97, 457) | < 0.001 | 14.7 (1.81, 190) | 0.01 |
| Diabetes Mellitus | 6.18 (1.51, 26.1) | 0.01 | 1.8 (0.151, 12.5) | 0.59 |
| Ischaemic Heart Disease | 17.4 (3.44, 115) | 0.001 | 4.25 (0.274, 45.6) | 0.27 |
| Surgical Intervention | 0.128 (0.0303, 0.484) | 0.002 | 0.592 (0.098, 4.82) | 0.59 |
Predictors of major adverse cardiovascular events
Pre-existing CKD (p-value = 0.002), DM (p-value = 0.04) and IHD (p-value = 0.02) were independently associated with a greater incidence of MACE in myxoma patients (Table 6). Surgical intervention was associated with decreased MACE incidence (p-value = 0.004). Age, sex, ethnicity, pre-existing hypertension and hyperlipidaemia were not associated with any differences in MACE incidence (p-value > 0.05). No variables remained significant after the multivariate regression (p-value > 0.05).
Table 6.
Logistic regression between major adverse cardiovascular events and patient characteristics.
| Characteristics | Univariate Odds Ratio (95% CI) | p-value | Multivariate Odds Ratio (95% CI) | p-value |
|---|---|---|---|---|
| Age | 1.15 (0.595, 2.36) | 0.69 | - | - |
| Male Sex | 1.46 (0.385, 6.59) | 0.58 | - | - |
| Chinese | 1 (ref) | - | - | - |
| Malay | 0.859 (0.0827, 4.81) | 0.87 | - | - |
| Indian | 8.11 (0.946, 98.7) | 0.06 | - | - |
| Other Ethnicity | 0.324 (0.0024, 3.21) | 0.39 | - | - |
| Hypertension | 1.96 (0.529, 7.84) | 0.31 | - | - |
| Hyperlipidaemia | 1.86 (0.491, 7.11) | 0.35 | - | - |
| Chronic Kidney Disease | 14 (2.57, 95.4) | 0.002 | 3.19 (0.345, 28.3) | 0.29 |
| Diabetes Mellitus | 4.95 (1.12, 21.7) | 0.04 | 2.09 (0.179, 15.3) | 0.51 |
| Ischaemic Heart Disease | 14 (2.57, 95.4) | 0.002 | 2.43 (0.171, 25) | 0.49 |
| Surgical Intervention | 0.0891 (0.0182, 0.363) | 0.001 | 0.201 (0.0328, 1.13) | 0.07 |
Survival time
The duration of follow-up was defined as the duration between the date of diagnosis and the date of death or 4 November 2022, whichever is earlier. The mean of follow-up duration was 5.80 ± 4.56 years. Given that CKD was a significant predictor of mortality, we stratified the 10-year survival rate of the cardiac myxoma cohort by the presence of CKD (Fig. 2).
Fig. 2.
Kaplan-Meier 10-year survival plot of cardiac myxoma cohort stratified by chronic kidney disease.
Discussion
In our study, we described a multiethnic Asian cohort of 64 patients with cardiac myxomas. We noted the presence of an increase in the pickup of asymptomatic cardiac myxoma patients after 2012. We found that some pre-existing medical conditions were associated with increased mortality rates and MACE incidence. We noted that surgical intervention was also associated with better mortality and decreased MACE incidence.
The population characteristics of our study differed from another cardiac myxoma cohort in Singapore, reported between January 2000 and December 20163. Our study had a higher proportion of male patients (61%) than their cohort (26.9%). Our study also had an older population (mean = 61.0 years old), as compared to their cohort (mean = 53.1 years old). However, we had similar rates of asymptomatic cardiac myxoma patients (30.2%) to their study (28.4%). The presence of systemic symptoms amongst symptomatic patients in our study (10.0%) was similar to theirs (10.4%). The predominant chamber of origin was the same between our study (left atrium, 82.8%) and theirs (left atrium, 88.1%). Traditionally, the majority of the cardiac myxomas were septal-involving in our study, which aligns with the current literature regarding their typical location14. However, there is a low prevalence of mid-diastolic murmur (1.6%) in our study as compared to what is typically reported (54%)15. This discrepancy may be attributable to the inherent challenge of detecting diastolic murmurs16,17, which are often subtle and heavily reliant on the examiner’s clinical experience.
In terms of the presentation, the majority of cardiac myxoma patients in our study (67.2%) were symptomatic at the time of diagnosis, consistent with findings in previous literature18,19. However, we noted an increase in the number of asymptomatic patients who were diagnosed with cardiac myxomas from 15.4% before 2012 to 35.3% after 2012. The initial low rate of asymptomatic patients (15.4%) aligns with prior studies, which reported rates as low as 2–7% between the 1980 s and 1990s19–22. The observed increase in the proportion of asymptomatic patients could be attributed to the increasingly widespread use of echocardiography, especially in other contexts like cardiac pre-operative assessment and routine health screening3, rather than an actual increase in the incidence of cardiac myxomas. Similar trends have been documented in Japan20, the United States23 and Singapore3. While it was not statistically significant, the greater mean age at diagnosis after 2012 likely reflects an older population of otherwise asymptomatic patients in whom cardiac myxomas were incidentally detected during echocardiograms performed for other indications. However, we did not note any statistical difference in mortality and MACE outcome between the symptomatic and asymptomatic patient groups. This suggests a limited role of population-wide screening in cardiac myxoma, given that screening targets asymptomatic patients and the overall low prevalence of the condition7. While incidental detection may not impact mortality and MACE outcome, early diagnosis and treatment could improve other clinical outcomes, such as surgical complications and recurrence rates24. Further research is needed to investigate the importance of incidental cardiac myxoma detection influencing long-term outcomes.
We analysed various predictors of mortality and MACE amongst the patients. Our results have shown that pre-existing medical conditions, such as CKD, IHD and DM, were associated with an increased mortality rate and MACE incidence in cardiac myxoma patients. In another cardiac myxoma cohort25, it was reported that CKD was the most significant mortality predictor. In our study, CKD was the only significant mortality predictor after multivariate regression of all significant pre-existing conditions. However, the role of CKD in influencing the mortality rate of cardiac myxoma patients remains unclear. CKD is often associated with cardiovascular diseases, which may remain subclinical until later on26–28. Further evaluation through echocardiography may thus be indicated to diagnose or prognosticate any cardiac abnormalities in these patients27,29. This may result in pickups of cardiac myxomas in CKD patients. The increased mortality rate in cardiac myxoma patients with CKD may reflect the severity of the underlying CKD, necessitating the echocardiogram, rather than the direct influence of CKD on the myxoma prognosis. However, cardiovascular complications of CKD26–28 could also potentially worsen the cardiac congestion in cardiac myxomas14. This could result in the otherwise rather benign condition having an increased mortality rate. In our study, we noted that there was a higher mortality rate amongst patients with right-sided cardiac involvement. However, this was likely confounded by the underlying comorbidities of CKD or IHD rather than the cardiac chamber involvement. Other studies have shown that age was a predictor of mortality14,30. Although statistically insignificant, our study showed that deceased patients were older than the survivors. However, this may reflect the natural increase in all-cause mortality risk with age31, rather than the influence of age on the prognosis of cardiac myxoma.
In our study, surgical intervention was associated with reduced mortality rate and MACE outcome. Currently, the mainstay treatment of cardiac myxoma is surgical removal14,32. It is well described that surgical resection of cardiac myxomas carries low perioperative risk with excellent early and long-term outcomes and low recurrence rates3,21,22,24,33,34. Hence, it is recommended for all suitable patients to undergo surgery. However, there are several factors which may influence the feasibility of surgery. Patient-related factors, such as their overall functional status and comorbidities, may influence the decision to proceed with the surgery due to greater susceptibility to the risks associated with general anaesthesia. Their pre-existing comorbidities may prohibit surgery in such patients, potentially resulting in poorer mortality and MACE outcomes that we observe in non-operated patients. This may potentially be reflected in the perceived benefits associated with surgical resection. Therefore, further studies investigating the comorbidity-adjusted management of cardiac myxoma may be needed to better understand the benefits, if any, of surgical resection. In addition, tumour characteristics, including the location, size, and familial association, influence the feasibility of the surgery and the patient’s postoperative prognosis. The location and size can complicate the surgical access, increasing the risk of intraoperative embolization1 and postoperative cerebrovascular complications25.
Familial cardiac myxomas are associated with a higher risk of postoperative recurrence rates of up to 10%35, requiring close monitoring post-operatively. When surgery is deemed unfeasible or during pre-operative periods, supportive medical management aims to address the symptoms and reduce the complication risk13. However, they were not shown to have any MACE benefits in other studies15. Cardiac myxomas can result in embolic symptoms, progressive cardiac failure and pulmonary oedema36. Antiplatelets and anticoagulants are used to prevent thromboembolic complications37. Arrhythmias, arising from the tumour’s interference with cardiac conduction38, can be effectively managed with beta blockers. Cardiovascular risk factors, including hypertension and hyperlipidaemia, can be optimised with ACEi/ARBs, beta blockers, calcium channel blockers, and statins. Heart failure symptoms can also be managed with ACEi/ARBs, diuretics, and MRA. Interestingly, in our study, patients who died were more likely to be on ACEi/ARBs. This could be explained by higher ACEi/ARB prescription rates in CKD patients (57.1%) than in non-CKD patients (15.8%). Given the association of CKD with increased mortality rates, the observed association could reflect the disease burden of CKD, rather than the impact of ACEi/ARB prescription. Further studies are needed to investigate the association between ACEi/ARB and the outcomes in cardiac myxoma patients, especially in non-CKD patients.
Our study had several limitations. As it is a single-centre cohort study with a small sample size, our mortality predictors had wide confidence intervals and should be considered during the interpretation of the results. Additionally, our study may lack generalisability to other centres as compared to multi-centre cohorts as the findings may be influenced by inclusion or referral bias. Furthermore, our study was only able to establish associations between variables and was unable to demonstrate any causative relationships. Future work can focus on further characterising the imaging findings of cardiac myxomas, based on their size and location, and associating them with the symptoms and outcomes of the condition.
Conclusion
In conclusion, we described a retrospective cohort of 64 multiethnic Asian patients with cardiac myxomas. We observed an increase in cardiac myxoma diagnosis in asymptomatic patients in our centre over the years. We found that pre-existing chronic kidney disease, ischaemic heart disease and diabetes mellitus were associated with poorer mortality outcomes, after adjustment for differences in baseline and clinical characteristics. Chronic kidney disease remained significant after multivariate logistic regression. Surgical resection was associated with a significantly decreased risk of mortality and MACE outcome in our patients as compared to when no surgical intervention was conducted and should be encouraged in all suitable patients. However, the poorer outcomes in non-operated patients may also be attributed to their underlying medical conditions that preclude surgery.
Supplementary Information
Below is the link to the electronic supplementary material.
Author contributions
I.S. and P.T. wrote the original manuscript draft. F.S. and T.L. conducted the data collection. I.S. conducted the data analysis and figure creation under the guidance of H.J. H.J., Y.H., and C.H. supervised the study. H.J., Y.H., C.H., K.K., W.K., M.C., P.C., T.C., L.Y., and B.T. reviewed and edited the manuscript.
Data availability
Data supporting the findings of this study are available upon reasonable request from the corresponding author. Requests for access to the data can be made by contacting Ching-Hui Sia at ching_hui_sia@nuhs.edu.sg.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
These authors First authors to this work: Irving Yu Le Shua and Pavarisa Tongboriboon.
References
- 1.Keeling, I. M. et al. Cardiac myxomas: 24 years of experience in 49 patients. Eur. J. Cardiothorac. Surg.22, 971–977 (2002). [DOI] [PubMed] [Google Scholar]
- 2.Nguyen, T., Vaidya, Y. Atrial Myxoma. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 3, 2023. [PubMed]
- 3.Lee, P. T., Hong, R., Pang, P. Y., Chua, Y. L. & Ding, Z. P. Clinical presentation of cardiac Myxoma in a Singapore National cardiac centre. Singap. Med. J.62, 195–198 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Flores, P. L., Haglund, F., Bhogal, P., Yeo Leong Litt, L. & Södermann, M. The dynamic natural history of cerebral aneurysms from cardiac myxomas: A review of the natural history of myxomatous aneurysms. Interv Neuroradiol. J. Peritherapeutic Neuroradiol. Surg. Proced. Relat. Neurosci.24, 277–283 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Wilkes, D., Charitakis, K. & Basson, C. T. Inherited disposition to cardiac Myxoma development. Nat. Rev. Cancer. 6, 157–165 (2006). [DOI] [PubMed] [Google Scholar]
- 6.Mahilmaran, A., Seshadri, M., Nayar, P. G., Sudarsana, G. & Abraham, K. A. Familial cardiac Myxoma. Tex. Heart Inst. J.30, 80–82 (2003). [PMC free article] [PubMed] [Google Scholar]
- 7.Islam, A. K. M. M. Cardiac myxomas: A narrative review. World J. Cardiol.14, 206–219 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Braun, S., Schrötter, H., Reynen, K., Schwencke, C. & Strasser, R. H. Myocardial infarction as complication of left atrial Myxoma. Int. J. Cardiol.101, 115–121 (2005). [DOI] [PubMed] [Google Scholar]
- 9.Oktaviono, Y. H. et al. Clinical characteristics and surgical outcomes of cardiac myxoma: A meta-analysis of worldwide experience. Eur. J. Surg. Oncol.50, 107940 (2024). [DOI] [PubMed] [Google Scholar]
- 10.Khan, M. S. et al. Cardiac myxoma: A surgical experience of 38 patients over 9 years, at SSKM hospital Kolkata, India. South. Asian J. Cancer. 2, 83–86 (2013). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Wang, J. G. et al. Clinicopathologic features and outcomes of primary cardiac tumors: a 16-year-experience with 212 patients at a Chinese medical center. Cardiovasc. Pathol.33, 45–54 (2018). [DOI] [PubMed] [Google Scholar]
- 12.Bosco, E., Hsueh, L., McConeghy, K. W., Gravenstein, S. & Saade, E. Major adverse cardiovascular event definitions used in observational analysis of administrative databases: a systematic review. BMC Med. Res. Methodol.21, 241 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Lone, R. A. et al. Atrial myxoma: trends in management. Int. J. Health Sci.2, 141–151 (2008). [PMC free article] [PubMed] [Google Scholar]
- 14.Reynen, K. & Cardiac Myxomas N Engl. J. Med.333, 1610–1617 (1995). [DOI] [PubMed] [Google Scholar]
- 15.Griborio-Guzman, A. G., Aseyev, O. I., Shah, H. & Sadreddini, M. Cardiac myxomas: clinical presentation, diagnosis and management. Heart108, 827–833 (2022). [DOI] [PubMed] [Google Scholar]
- 16.Davidsen, A. H. et al. Diagnostic accuracy of heart auscultation for detecting valve disease: a systematic review. BMJ Open.13, e068121 (2023). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Walker, H.K., Hall, W.D., Hurst, J.W. (eds.) Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston: Butterworths; p. 138-146, (1990). [PubMed]
- 18.Aggarwal, S. K. et al. Clinical presentation and investigation findings in cardiac myxomas: new insights from the developing world. Am. Heart J.154, 1102–1107 (2007). [DOI] [PubMed] [Google Scholar]
- 19.Goswami, K. C. et al. Cardiac myxomas: clinical and echocardiographic profile. Int. J. Cardiol.63, 251–259 (1998). [DOI] [PubMed] [Google Scholar]
- 20.Yuda, S. et al. Trends in the clinical and morphological characteristics of cardiac Myxoma. Circ. J.66, 1008–1013 (2002). [DOI] [PubMed] [Google Scholar]
- 21.Miralles, A. et al. Cardiac tumors: clinical experience and surgical results in 74 patients. Ann. Thorac. Surg.52, 886–895 (1991). [DOI] [PubMed] [Google Scholar]
- 22.Blondeau, P. Primary cardiac tumors–French studies of 533 cases. Thorac. Cardiovasc. Surg.38 (Suppl 2), 192–195 (1990). [DOI] [PubMed] [Google Scholar]
- 23.Gui, J., Maqsood, A., Khadka, S., Rodriguez, K. & Everett, G. New trend of cardiac Myxoma - Case series and systematic review. Clin. Cardiol. Cardiovasc. Med.1–510.33805/2639.6807.101 (2016).
- 24.Vroomen, M., Houthuizen, P., Khamooshian, A., Soliman Hamad, M. A. & van Straten, A. H. M. Long-term follow-up of 82 patients after surgical excision of atrial myxomas. Interact. Cardiovasc. Thorac. Surg.21, 183–188 (2015). [DOI] [PubMed] [Google Scholar]
- 25.Tulin, R. et al. Predictors of Late Mortality in Patients With Surgically Resected Cardiac Myxomas: A Single-Center Experience. Cureus 14, e20866. [DOI] [PMC free article] [PubMed]
- 26.Franczyk-Skóra, B., Gluba, A., Olszewski, R., Banach, M. & Rysz, J. Heart function disturbances in chronic kidney disease - echocardiographic indices. Arch. Med. Sci. AMS. 10, 1109–1116 (2014). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Pecoits-Filho, R. & Barberato, S. H. Echocardiography in chronic kidney disease: diagnostic and prognostic implications. Nephron Clin. Pract.114, c242–c247 (2010). [DOI] [PubMed] [Google Scholar]
- 28.Di Lullo, L. et al. Chronic kidney disease and cardiovascular complications. Heart Fail. Rev.20, 259–272 (2015). [DOI] [PubMed] [Google Scholar]
- 29.Liu, Y. W. et al. The role of echocardiographic study in patients with chronic kidney disease. J. Formos. Med. Assoc.114, 797–805 (2015). [DOI] [PubMed] [Google Scholar]
- 30.Jiang, C. X. et al. Long-term outcome of patients with atrial Myxoma after surgical intervention: analysis of 403 cases. J. Geriatr. Cardiol. JGC. 16, 338–343 (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Global regional, and National age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the global burden of disease study 2013. Lancet385, 117–171 (2015). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Jain, S., Maleszewski, J. J., Stephenson, C. R. & Klarich, K. W. Current diagnosis and management of cardiac myxomas. Expert Rev. Cardiovasc. Ther13, 369–375 (2015). [DOI] [PubMed]
- 33.Alhasso, A. A. et al. Operative management and outcomes in patients with myxomas: A single-center experience. Front Surg10, 1084447 (2023). [DOI] [PMC free article] [PubMed]
- 34.Luo, C., Zhu, J., Bao, C., Ding, F. & Mei, J. Minimally invasive and conventional surgical treatment of primary benign cardiac tumors. J. Cardiothorac. Surg.14, 76 (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.McCarthy, P. M. et al. The significance of multiple, recurrent, and ‘complex’ cardiac myxomas. J. Thorac. Cardiovasc. Surg.91, 389–396 (1986). [PubMed] [Google Scholar]
- 36.Butany, J. et al. Cardiac tumours: diagnosis and management. Lancet Oncol.6, 219–228 (2005). [DOI] [PubMed] [Google Scholar]
- 37.Chen, Y., Huang, Q., Bai, C., Zhang, H. & Zhang, B. Preoperative management and anticoagulant efficacy in atrial myxoma-associated acute ischemic stroke: a case report and literature review. Front Cardiovasc. Med.11, 1435047 (2024). [DOI] [PMC free article] [PubMed]
- 38.Jayaprakash, S. Clinical presentations, diagnosis, and management of arrhythmias associated with cardiac tumors. J. Arrhythmia. 34, 384–393 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data supporting the findings of this study are available upon reasonable request from the corresponding author. Requests for access to the data can be made by contacting Ching-Hui Sia at ching_hui_sia@nuhs.edu.sg.