How to detect a left atrial myxoma by auscultation

A male patient in his sixties complaints on dyspnoea and near syncope.  This is his Echo:



A large oval pedunculated tumour is attached to IAS.  This is the typical left atrial myxoma.  In this case, the diagnosis was made by echocardiography.  However, is it possible to find left atrial myxoma bedside? 

Sometimes it is possible.  But cardiac myxomas are a rare illness.  It is almost impossible to get corresponding experience auscultating a lot of such patients.  

Our patient had clear and bright auscultatory picture.  You can learn this case and probably one day you will make the correct diagnosis by auscultation alone.

Firstly, let us talk about some theory about auscultatory signs of myxomas.  Most of them are located in the left atrium and attached to IAS by thin peduncle near the fossa ovalis. In diastole, myxoma can move toward left ventricle partially obstructing mitral valve's orifice.  That is all.  What can we hear?

Partial obstruction of the mitral valve's orifice leads to the mitral stenosis.  Mitral stenosis causes loud S1 (1 on the picture above) and diastolic low-frequency murmur (3 on the picture above).  
Quick diastolic movement of the myxoma toward left ventricle can produce additional diastolic sound.  Ther are two possible explanation of this sound: a sudden tension of peduncle of myxoma and a   myxoma's kick against the mitral annulus.  If a patient has sinus rhythm, the blood moves into the left ventricle in two phases: the early phase of passive ventricle's filling and the late phase of left atrial's contraction.  That is why left atrial myxoma can move twice and can produce two diastolic sounds: at the early diastole just after S2 and at the late diastole just before S1 (2 on the picture above).  These are rather low-frequency sounds.  Contrary to S3 and S4, the time interval between tumour sound and closest S2 or S1 is not constant.  
Tumour sound in the early diastole could be misinterpreted like opening snap of mitral valvular stenosis, especially when the diastolic rumble is present.  Remember, that opening snap is even more stable in quality and time of appearance,  than S3.

Now, let us listen to our patient.  

Apex of the heart, supine position.  Note abnormally loud S1:

The point between apex and tricuspid point, supine position.  Not additional sound just before S1:

Tricuspid point, supine position.  Not additional sound just before S1:

Erb's point, supine position.  Note loud S1 and S2.  Additional late systolic sound is also present.  This patient had severe pulmonary hypertension; that is why S2 was accentuated.  Systolic murmur which is present on some recordings is a sign of mild tricuspid regurgitation.  


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