Anaesthesiologist’s role beyond haemodynamics: Transoesophageal echo-guided surgical decision-making in right atrial myxoma coexisting with secundum atrial septal defect

Dear Editor,

The perioperative role of the cardiac anaesthesiologist has expanded considerably, extending beyond haemodynamic management to imaging-guided surgical decision-making. We present a rare case of right atrial (RA) myxoma arising from the eustachian valve with inferior vena cava (IVC) extension and coexisting secundum atrial septal defect (ASD), underscoring the utility of intraoperative transoesophageal echocardiography (TEE).

A 26-year-old female patient with hypothyroidism presented with New York Heart Association (NYHA) class II dyspnoea, palpitations, and recurrent nausea. Transthoracic echocardiography (TTE) revealed an ostium secundum ASD measuring 1.4 × 1.2 cm and a mobile mass at the IVC–RA junction protruding into the left atrium, raising concern for embolisation and difficulty with IVC cannulation for cardiopulmonary bypass (CPB). Given her symptoms and embolic risk, urgent surgery was planned. Cardiac computed tomography and magnetic resonance imaging were deferred due to time and cost constraints, consistent with reviews identifying echocardiography as the primary diagnostic modality for cardiac myxomas.[1,2]

Following anaesthetic induction, invasive arterial monitoring and central venous access were established. A Philips X7-2T matrix-array TEE probe was inserted, and comprehensive intraoperative multiplane 2D and real-time 3D image acquisitions were performed in accordance with guideline-based recommendations.[2,3,4] TEE demonstrated a lobulated, pedunculated “cauliflower-shaped” mass measuring 4 × 4.5 cm attached to the Eustachian valve at the IVC–RA junction, intermittently extending into the proximal IVC without obstruction [Figure 1a-d]. The intrahepatic IVC was completely free of tumour [Figure 1d]. A large secundum ASD with a preserved IVC rim was confirmed, and the mass tip was seen prolapsing into the left atrium through the ASD during parts of the cardiac cycle [Figure 1a-c].

Figure 1.

Intraoperative real-time 2D and 3D transoesophageal echocardiographic images and histopathology. a) Mid-oesophageal aortic valve short-axis view (modified) showing a “cauliflower-shaped” pedunculated mass attached to the Eustachian valve at the IVC–RA junction, extending into the right atrium and protruding into the left atrium through a coexisting ASD. b) Mid-oesophageal bicaval view in real-time 3D TEE, single-beat acquisition at a multiplane angle of 95–110°, demonstrating the right atrial mass briefly extending into the IVC. c) Mid-oesophageal bicaval 2D view at a multiplane angle of 95–110°, demonstrating tumour attachment to the Eustachian valve and its extension into the right atrium and proximal IVC. d) Intrahepatic IVC view obtained from the lower oesophagus at a multiplane angle of 65° with rightward probe rotation, showing a tumour-free IVC and unobstructed blood flow on colour Doppler. e) Postoperative real-time 3D mid-oesophageal view, single-beat acquisition at a multiplane angle of 60°, showing a tumour-free right atrium and IVC with surgically repaired ASD using a pericardial patch. f) Postoperative mid-oesophageal bicaval view at a multiplane angle of 110°, showing a tumour-free IVC and right atrium and a closed ASD with pericardial patch. g) Histopathology of the excised mass (H and E stain, ×100) showing myxoid tissue with degenerative changes, confirming right atrial myxoma. IVC: Inferior vena cava; IVC-RA: Inferior vena cava-right atrial; ASD: Atrial septal defect

The lesion’s gelatinous, lobulated, pedunculated, and highly mobile nature strongly favoured myxoma as the diagnosis. In contrast, thrombi are typically sessile and linked to stasis or indwelling catheters, papillary fibroelastomas are small and valve-attached, lipomas are homogeneously encapsulated, and metastases or vegetations are irregular and infiltrative. Normal right atrial variants (e.g., prominent Eustachian valve or Chiari network) lack a distinct stalk and significant prolapse.[1,5] Although echocardiography cannot provide definitive tissue characterisation, the findings strongly suggested RA myxoma.

TEE delineated the craniocaudal extent of the tumour and confirmed its confinement to the eustachian valve and proximal IVC, with no intrahepatic IVC or pulmonary artery involvement. These findings reassured the operating team that direct bicaval cannulation could be performed without traversing the tumour, minimising the need for deep hypothermic circulatory arrest (DHCA). Femoral venous cannulation was avoided as advancing a femoral cannula across the IVC–RA junction would have risked mechanical disruption and embolisation. Nevertheless, similar right-sided tumours near the IVC orifice have prompted alternative cannulation strategies to avoid tumour manipulation.[3]

CPB was instituted with aortic and bicaval cannulation under TEE guidance. Moderate hypothermic circulatory arrest (MHCA) at 26°C for 5 minutes provided a bloodless field at the IVC orifice for precise excision. Surgical findings perfectly matched the TEE images: a pedunculated mass arising from the Eustachian valve, extending into the proximal IVC, with a tumour-free intrahepatic IVC [Figure 2a]. The mass was excised en bloc with Eustachian valve tissue, and the ASD was closed with an autologous pericardial patch [Figure 2b, 2c]. After weaning from CPB, repeat TEE confirmed complete excision of the mass with a tumour-free right atrium and IVC, unobstructed venous return, and a well-seated patch with no residual shunt [Figure 1e, 1f]. The postoperative course was uneventful. Histopathological examination of the excised tumour confirmed the diagnosis, demonstrating classic myxoid stroma with characteristic myxomatous cells [Figure 1g].[1,5]

Figure 2.

Intraoperative surgical views of the right atrial myxoma. a) Intraoperative view after opening the right atrium, showing a myxoma arising from the Eustachian valve and covering the IVC orifice. An ostium secundum ASD is visible in the inferior portion of the field, with cannulation and snaring of both the superior and inferior venae cavae and a left atrial vent passed through the ASD. b) “Cauliflower-shaped” pedunculated tumour following complete excision, including its stalk attached to the eustachian valve. c) Post-excision view before right atrial closure, demonstrating a tumour-free IVC and right atrium and pericardial patch closure of the ASD. IVC: Inferior vena cava; RA:Right atrium; OS-ASD: Ostium secundum-Atrial septal defect

Cardiac myxomas are the most common primary cardiac tumours, but RA myxomas constitute only 10–20% of cases. Tumours originating from the Eustachian valve with IVC extension and coexisting secundum ASD are exceptionally rare, with isolated reports highlighting their dual risk of pulmonary and paradoxical systemic embolisation.[1,5] The utilisation of brief MHCA as an alternative to DHCA has been shown to enhance postoperative outcomes following cardiac surgery.[6]

Intraoperative 2D and 3D TEE extended the anaesthesiologist’s role beyond haemodynamic monitoring to imaging-guided surgical decision-making. It delineated tumour attachment, excluded extension into the intrahepatic IVC and pulmonary artery, guided bicaval cannulation over femoral access, and enabled use of brief MHCA instead of prolonged DHCA, aligning with current guidelines and contributing to the favourable outcome.

Declaration of Patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient consented to the images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Author contributions

ABS and GGS conceptualised the study and prepared the initial manuscript draft. AAG performed the literature search and was responsible for data acquisition. VMD provided the histopathology details and contributed to critical revision of the manuscript. ABS performed the final overall review. All authors read, revised, and approved the final version of the manuscript.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

This is an original clinical case study and supportive review literature was obtained from library sources. The use of AI has not been done in the present article.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.