Correspondence (reply): In Reply

The additional points raised in the correspondence from an ophthalmologist's perspective underlines once more one of the key messages of our study on the most common cardiac tumors—namely, that these tumors can display chameleon-like qualities in the context of their diagnostic evaluation. We did point out the development of potentially fatal embolisms, especially in cases of myxoma. Any embolism that has developed, independently of its location, needs to be investigated by histology as well as echocardiography, in order to be able to exclude thrombi, endocarditis vegetations, or cardiac tumors as possible causes. It is well known that 30-40% of all untreated myxomas will embolize, and some investigators have reported such embolizations as the most common clinical manifestation of this gelatinous and friable tumor (1). Myxomas have been reported to be responsible for 0.4% of all cases of stroke. Fundamentally, however, any vascular region may be affected. We are now studying cardiac tumors from three university medical centers—we have not observed a single case of severe embolization into the ocular arteries over 40 years. A PubMed search using the search term “cardiac tumor” identified 42 000 publications; refining the search by adding “retinal occlusion” resulted in 24 individual case reports that described embolizations into the central ocular artery. Because of the serious sequelae of a tumor-related embolism—in whichever area of the body—regular transesophageal echocardiography in the treating center is essential, perioperatively, postoperatively, and in case of any new clinical symptoms.

Schmidt et al. used the term “metastatic myxoma” in the context of embolisms. We are not familiar with the term in this context, but it is used occasionally in the literature in the context of the discussion about potential malignant transformation of myxomas.