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\begin{document}

\title{ACCURACY OF TRANSTHORACIC ECHOCARDIOGRAPHY IN DIAGNOSIS OF CARDIAC
MYXOMA: SINGLE CENTRE EXPERIENCE}



\author[1]{Katja Prokšelj}%
\author[1]{Polona Kačar}%
\author[1]{Nejc Pavšič}%
\author[1]{Mojca Bervar}%
\author[2]{Zvezdana Dolenc Stražar}%
\affil[1]{Department of Cardiology University Medical Center Ljubljana Zaloska cesta 7 1525 Ljubljana Slovenia}%
\affil[2]{Univerza v Ljubljani Medicinska Fakulteta}%


\vspace{-1em}



  
  \date{June 13, 2024}


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\selectlanguage{english}
\begin{abstract}
The differential diagnosis of cardiac myxomas (CM), the most common
benign primary cardiac tumors, is broad and a thorough diagnostic workup
is required to establish accurate diagnosis prior to surgical resection.
Transthoracic echocardiography (TTE) is usually the first imaging
modality used for diagnosis of suspected CM. \textbf{Purpose} In a
single tertiary centre study, we sought to determine the accuracy,
sensitivity, and specificity of TTE in the diagnosis of CM and to
determine echocardiographic characteristics indicative of CM.
\textbf{Methods and results} We retrospectively analyzed clinical,
echocardiographic, and pathohistological findings of 73 patients
consecutively admitted for suspected CM. After diagnostic workup, 53
(73\%) patients were treated surgically at our institution. Based on
preoperative TTE, patients were divided into a CM group (n=45, 85\%) and
non-myxoma (NM) group. Of the 53 pathohistological specimens obtained
during surgery, 39 (73\%) were CM. The sensitivity and specificity of
preoperative echocardiography were 97\% and 50\%, respectively. The
overall accuracy was 85\%. All NM tumors were found in an atypical
location and 72\% of CM were found in a typical position in the left
atrium (p\textless{}0.001). Tumors in NM group were significantly
smaller than CM (24.3\selectlanguage{ngerman}±13.2 mm vs 37.9±18.3 mm, p=0.017).
\textbf{Conclusion} Our study confirms very good accuracy of TTE in the
diagnosis of CM. The most important echocardiographic characteristics to
differentiate between CM and tumors of different etiology are tumor
location and size. Smaller tumors presenting at an atypical location are
less likely to be diagnosed as CM, and these require additional imaging
modalities for accurate diagnosis.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{ACCURACY OF TRANSTHORACIC ECHOCARDIOGRAPHY IN DIAGNOSIS OF
CARDIAC MYXOMA: SINGLE CENTRE EXPERIENCE}

Polona Ka\selectlanguage{polish}č\selectlanguage{english}ar, MD\textsuperscript{a}, Nejc Pav\selectlanguage{polish}š\selectlanguage{english}i\selectlanguage{polish}č, \selectlanguage{english}MD\textsuperscript{a},
Mojca Bervar, MD, PhD\textsuperscript{a}, Zvezdana Dolenc Stra\selectlanguage{polish}ž\selectlanguage{english}ar,
MD\textsuperscript{b}, assist. prof. Katja Prok\selectlanguage{polish}š\selectlanguage{english}elj, MD,
PhD\textsuperscript{a,b*}

Department of Cardiology, University Medical Center Ljubljana, Zaloska
cesta 7, 1525 Ljubljana, Slovenia

Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000
Ljubljana

*Corresponding author: Katja Prok\selectlanguage{polish}š\selectlanguage{english}elj, katja.prokselj@gmail.com, tel.
+(386)1-522-8572, fax. +(386)1-522-2828

\textbf{Abstract}

The differential diagnosis of cardiac myxomas (CM), the most common
benign primary cardiac tumors, is broad and a thorough diagnostic workup
is required to establish accurate diagnosis prior to surgical resection.
Transthoracic echocardiography (TTE) is usually the first imaging
modality used for diagnosis of suspected CM.

\textbf{Purpose}

In a single tertiary centre study, we sought to determine the accuracy,
sensitivity, and specificity of TTE in the diagnosis of CM and to
determine echocardiographic characteristics indicative of CM.

\textbf{Methods and results}

We retrospectively analyzed clinical, echocardiographic, and
pathohistological findings of 73 patients consecutively admitted for
suspected CM. After diagnostic workup, 53 (73\%) patients were treated
surgically at our institution. Based on preoperative TTE, patients were
divided into a CM group (n=45, 85\%) and non-myxoma (NM) group. Of the
53 pathohistological specimens obtained during surgery, 39 (73\%) were
CM. The sensitivity and specificity of preoperative echocardiography
were 97\% and 50\%, respectively. The overall accuracy was 85\%. All NM
tumors were found in an atypical location and 72\% of CM were found in a
typical position in the left atrium (p\textless{}0.001). Tumors in NM
group were significantly smaller than CM (24.3\selectlanguage{ngerman}±13.2 mm vs 37.9±18.3 mm,
p=0.017).

\textbf{Conclusion}

Our study confirms very good accuracy of TTE in the diagnosis of CM. The
most important echocardiographic characteristics to differentiate
between CM and tumors of different etiology are tumor location and size.
Smaller tumors presenting at an atypical location are less likely to be
diagnosed as CM, and these require additional imaging modalities for
accurate diagnosis.

\textbf{Keywords:} cardiac mass; cardiac myxoma; cardiovascular imaging;
echocardiography

\textbf{Introduction}

Although rare, cardiac myxoma (CM) represents the most common benign
primary cardiac tumor{[}1{]}. Many patients are asymptomatic and CM is
often an incidental finding{[}2{]}. Potentially life-threatening
complications such as tumor obstruction or embolization can occur,
making accurate diagnosis crucial {[}3,4{]}. However, diagnosis is
challenging due to the broad differential diagnosis of CM, which
includes other cardiac tumors and cardiac masses such as thrombi,
vegetations, calcific lesions, and other rare conditions.

Transthoracic echocardiography (TTE) nowadays represents the most
commonly used initial imaging modality in the diagnostic workup of CM.
It provides information on tumor size, location, attachment point,
morphology, mobility, and its relation to surrounding structures. The
majority of CM are located in the left atrium, attached to the atrial
septum in the region of the fossa ovalis. These are considered as
typical CM, but atypical localizations outside the left atrium have been
described in around 30\% {[}5{]}. Size and appearance (solid and round
or polypoid) may also vary considerably in CM {[}6{]}.

TTE has an excellent detection rate for CM and a sensitivity of 90--96\%
in diagnosing CM has been reported {[}4{]}. However, the heterogeneous
morphological presentation leads to overlap with other cardiac masses
and may affect the specificity and accuracy of TTE in CM diagnosis.
Furthermore, TTE lacks tissue characterization {[}7{]}. Multimodality
cardiac imaging ensures a more detailed analysis. Ultimately, the final
diagnosis is made by histopathological examination of the excised tumor
{[}8{]}.

The aim of our single-center study was to evaluate the utility and
accuracy of TTE in the diagnosis of CM and to determine
echocardiographic characteristics indicative of pathohistologically
confirmed CM.

\textbf{Methods}

We retrospectively analyzed clinical, echocardiographic, and
pathohistological findings of all consecutive adult patients (\selectlanguage{english}[?]18 years
of age) referred to our Department of Cardiology for suspected CM
between 2005 and 2020.

All patients had TTE performed as part of the standard diagnostic
workup. Echocardiographic characteristics of the cardiac mass were
obtained, including mass location, surface (smooth or lobulated vs.
villous) and appearance (homogenous vs. heterogenous). The mobility of
the mass and the presence or absence of obstruction were also noted.
Based on TTE findings, patients were diagnosed with either CM, other
non-myxomal (NM) cardiac tumor, or cardiac masses of other etiology
(thrombus, infective endocarditis, etc.). Diagnosis of CM was made
individually by the cardiologist performing TTE based on typical
morphological characteristics of the cardiac mass. In some cases,
additional imaging methods were used, either due to poor TTE acoustic
windows or atypical tumor presentation. TTE contrast imaging was not
performed in any of the cases.

Patients with CM or NM cardiac tumors were referred for surgery and
pathohistological samples of the tumors were collected and analyzed to
determine the final diagnosis. The accuracy, sensitivity, and
specificity of TTE were determined by comparing echocardiographic and
pathohistological diagnosis. Furthermore, echocardiographic
characteristics of pathohistologically proven CM were compared to NM
cardiac tumors. The study was approved by the national ethics committee
and it has been carried out in accordance with the Declaration of
Helsinki.

\emph{Statistical analysis}

Continuous variables are presented as mean +- standard deviation and
categorical variables as numbers and percentage. The independent
Student's t-test was used to compare continuous variables. Categorical
variables were analyzed using the \selectlanguage{greek}χ\selectlanguage{english}\textsuperscript{2}test. The
sensitivity, specificity, negative predictive value, and positive
predictive value of echocardiographic diagnosis of CM were calculated
using the results of pathohistological examination as the gold standard.
Accuracy was determined as the sum of true negative and positive tests
divided by all tests. All statistical analyzes were performed using SPSS
version 26.0 software. Values of p\textless{}0.05 were considered
statistically significant.

\textbf{Results}

\emph{Baseline characteristics}

During the 15-year period, 73 patients were referred for evaluation of
suspected CM. All patients underwent TTE and 63 (86\%) were diagnosed
with CM or NM cardiac tumor. Of the remaining 10 (14\%) patients, five
were diagnosed with thrombus and were treated accordingly with
anticoagulation therapy. In three cases pseudotumor was diagnosed; one
had a prominent Eustachian valve, one had a prominent Chiari network,
and one had lipomatous hypertrophy of the interatrial septum. In two
patients no obvious cardiac mass was found on repeat TTE.

In 56 cases (77\%) additional imaging techniques were used to confirm
the diagnosis, either due to suboptimal image quality on TTE or atypical
tumor presentation. CMR was used most frequently (n=25, 34\%), followed
by TEE (n=24, 33\%) and CT (n=5, 7\%). In two patients PET-CT was
performed to detect possible distant metastases. No working diagnosis
changed after additional imaging techniques.

After complete diagnostic workup, 53 (84\%) of the 63 patients diagnosed
with either CM or NM were referred for surgery at our institution. One
patient underwent surgery at another institution and was not included in
further analysis. The remaining 9 patients did not undergo surgery,
either due to poor clinical condition (n=4) or patient's choice (n=1).
In four patients the mass was very small and periodic TTE follow-up was
indicated.

The mean age of the operated patients was 64\selectlanguage{ngerman}±14 years (26--85 years), 35
patients (66\%) were female. The most common complaint was dyspnea (18
patients, 34\%), followed by embolic events in 8 patients (15\%), chest
pain in 5 patients (9\%), constitutional signs in 3 patients (6\%) and
palpitations in 2 patients (4\%). Seventeen patients (32\%) were
asymptomatic. The mass was an incidental finding in 23 patients (43\%),
most commonly on TTE (61\%) and chest CT (39\%) performed for other
indication.

\emph{Echocardiographic characteristics}

Based on preoperative echocardiographic findings, the 53 operated
patients were divided into two groups: a CM group (45 patients, 85\%)
and a NM group (8 patients, 15\%). Preoperative echocardiographic
characteristics are depicted in Table I. All tumors were solitary. The
mean tumor size in the CM group was 35.3±18.6 mm (range: 10--81 mm). The
majority of CM were located in the atria; 80\% in the left atrium and
18\% in the right atrium. One tumor was found in the left ventricle.
Tumors found in the left atrium were most frequently attached to the
atrial septum in the region of the fossa ovalis (n=27, 75\%) (Figure 1).
Other attachment sites in the left atrium included the mitral valve
(n=4, two were attached to the posterior leaflet, one to the anterior
leaflet, and one to the posterior annulus of the mitral valve), other
areas of the atrial septum (n=3, posterior part of the atrial septum),
the free atrial wall (n=1) and left atrial appendage (n=1). The tumors
were mostly mobile (n=32, 71\%). Mitral valve obstruction was observed
in 10 (22\%) patients and tricuspid valve obstruction in 1 (2\%)
patient.

The mean tumor size in the NM group was 30.3±16.9 mm (range: 8--50 mm)
(Table I). All NM tumors were found in an atypical location, most
frequently in the right atrium (n=4, 50\%). Two were attached to the
left atrial free wall or posterior mitral valve leaflet and one to the
aortic valve.

\emph{TTE sensitivity, specificity, and accuracy analysis}

Pathohistological samples were obtained from the resected tumors in all
53 surgical procedures performed at our institution. Pathohistological
evaluation confirmed CM in 39 of 53 operated patients (73\%) (Figure 1).

The calculated sensitivity and specificity of preoperative
echocardiography were 97\% and 50\%, respectively. The overall accuracy
of TTE in diagnosing CM was 85\% (Figure 2). In 7 patients (13\%)
diagnosed as CM on preoperative TTE, pathohistology revealed different
NM cardiac tumors: papillary fibroelastoma in 5 cases, one case of
angioleiomyoma and one malignant melanoma metastasis. Only one patient
preoperatively classified as NM cardiac tumor had CM.

Pathohistologically confirmed NM cardiac tumors were significantly
smaller than CM (24.3±13.2 mm vs 37.9±18.3 mm, p=0.017) (Table II).
There was also a statistically significant difference in tumor location
between the two groups. All NM tumors were located at an atypical
position (seven in the right atrium, five in the left atrium but at an
atypical site and two in the left ventricle) and 72\% of CM were found
at the typical location within the left atrium (p\textless{}0.001). The
calculated sensitivity and specificity of tumor location in diagnosis of
myxoma was 100\% and 56\%, respectively. There was no significant
difference in other demographic (age, sex) or echocardiographic
characteristics (mobility, surface, appearance) between groups.

\textbf{Discussion}

Our single-center study confirms very good overall accuracy of TTE in CM
diagnosis. This is clinically important as accurate assessment of
cardiac masses is essential for appropriate clinical management and
treatment of these patients.

Diagnosis of CM can be challenging since patients are frequently
asymptomatic or have only non-specific signs and symptoms. Dyspnea, a
frequent and non-specific symptom of cardiac disease, was the most
common complaint in our CM group, which is consistent with previous
reports {[}9--11{]}. Clinical presentation itself rarely suggests the
diagnosis of CM; therefore, cardiac imaging is essential in the
evaluation of patients with suspected CM. Echocardiography is the most
widely used imaging modality that provides important information about
the location, size, and appearance of the cardiac mass, as well as
possible complications (e.g. obstruction). Previous studies have shown
that CM are typically solitary, located in the left atrium, smooth in
surface and mobile {[}12,13{]}. However, the morphological presentations
of CM are often atypical and heterogeneous, leading to overlap with
other NM cardiac tumors and cardiac masses.

The results of our study show very good overall accuracy (85\%) of TTE
in CM diagnosis with excellent sensitivity (97\%). However, the
specificity of TTE is modest (50\%) and caution is warranted as
misdiagnosis of CM is possible. In our study, 5 of the misdiagnosed
cases of CM were actually papillary fibroelastoma, which is also a
common primary benign cardiac tumor. One of the suspected CM was
actually a metastasis of malignant melanoma, underlying the importance
of surgical excision and pathohistological examination of all suspected
CM.

According to our results tumor localization and tumor size are the best
echocardiographic characteristics to distinguish between CM and NM
cardiac tumors. CM are typically located in the left atrium attached to
the interatrial septum at the region of fossa ovalis, which was also
shown in our study {[}14{]}. In our patients, 72\% of CM were located
typically. However, all tumors preoperatively misdiagnosed as CM were
located in atypical locations, such as the right atrium and left
ventricle. Tumors in the NM group were also significantly smaller
compared to tumors in the CM group. However, there was no significant
difference in age, sex, and other echocardiographic characteristics
(mobility and surface) between the groups.

The differential diagnosis of CM is broad and definite diagnosis is
crucial, as treatment varies depending on the diagnosis. Multimodality
cardiac imaging improves the diagnostic accuracy of different cardiac
masses. In the majority of our patients, at least one additional imaging
modality was used as a part of the diagnostic workup. TEE improves image
quality and provides more morphological information than TTE {[}15{]}.
Computed tomography and cardiac magnetic resonance provide additional
information on topographic relationships and tissue characteristics, and
may detect other pathological conditions within the thorax {[}16,17{]}.
Assessment of cardiac tumors by CMR is more accurate than
echocardiography and can reliably distinguish between benign and
malignant cardiac tumors {[}18--20{]}.

There are some limitations to this study. First, this is a retrospective
study with a relatively small study population. However, the population
size is comparable to other studies on CM. Due to the low incidence of
cardiac tumors, only multicenter studies can provide a larger scale
patient population. Second, preoperative echocardiography was performed
by different echocardiographers, potentially exposing the results to
inter-investigator variability in determining the diagnosis. Due to the
study inherently including participants already given a working
diagnosis of CM, any cardiologist performing TTE was likely influenced
by the information provided upon referral. A larger, multicenter,
prospective study could serve to identify echocardiographic and clinical
characteristics specific to CM, as well as other cardiac tumors, further
increasing the utility of preoperative diagnostic modalities.

\textbf{Conclusions}

TTE is very accurate in diagnosing CM. Tumor localization and size are
the most important echocardiographic characteristics that can
differentiate between CM and NM. The diagnosis of CM is less likely in
atypical tumor location and smaller tumor size. In such cases, caution
is advised and other non-invasive imaging modalities, such as CMR or CT,
should be performed to confirm the diagnosis.

\textbf{Author contributions}

The concept of this article was designed by Katja Prok\selectlanguage{polish}š\selectlanguage{english}elj. Nejc Pav\selectlanguage{polish}š\selectlanguage{english}i\selectlanguage{polish}č
\selectlanguage{english}and Polona Ka\selectlanguage{polish}č\selectlanguage{english}ar collected the data and wrote the draft of the article.
Polona Ka\selectlanguage{polish}č\selectlanguage{english}ar analyzed the data. Critical revision of the article was
made by Mojca Bervar, Zvezdana Dolenc Stra\selectlanguage{polish}ž\selectlanguage{english}ar and Katja Prok\selectlanguage{polish}š\selectlanguage{english}elj.

\textbf{Declarations}

Conflicts of interest: The authors declare that they have no conflict of
interest.

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\textbf{Table I.} Preoperative echocardiographic characteristics of the
cardiac myxoma (CM) and non-myxoma (NM) group\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
Echocardiographic characteristics\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
CM (n=45)\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
NM (n=8)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Mean size (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
35.3\selectlanguage{ngerman}±18.6 (range: 10--81)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
30.3\selectlanguage{ngerman}±16.9 (range: 8--50)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Location\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Left atrium\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
36 (80)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
2 (25)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Fossa ovalis\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
27 (75)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Mitral valve\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
4 (11)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (50)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Posterior interatrial septum\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
3 (8)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Free left atrial wall\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (3)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (50)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Left atrial appendage\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (3)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Right atrium\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
8 (18)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
4 (50)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Left ventricle Aortic valve\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (2)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (12) 1 (12)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Mobility\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Mobile Non-mobile No data available\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
32 (71) 5 (11) 8 (18)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
7 (88) 1 (12)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Surface\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Smooth or lobulated\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
28 (62)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (12)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Villous No data available\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
8 (18) 9 (20)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
3 (38) 4 (50)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Obstruction (present)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
11 (24)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
2 (25)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Mitral valve\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
10 (21)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (50)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Tricuspid valve\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (9)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (50)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Values are presented as mean \selectlanguage{ngerman}± standard deviation or number
(percentage).

\textbf{Table II.} Comparison of demographic and echocardiographic
characteristics between pathohistologically confirmed cardiac myxoma
(CM) and non-myxoma (NM) groups.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Characteristic\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
CM (n=39)\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
NM (n=14)\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
p value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Age (years)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
63.1\selectlanguage{ngerman}±13.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
66.6\selectlanguage{ngerman}±15.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.434\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Sex (female)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
25 (64)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
10 (71)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.620\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Location\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Typical\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
28 (72)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
p\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Atypical\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
11 (28)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
14 (100)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
p\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Size (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
37.9\selectlanguage{ngerman}±18.3\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
24.3\selectlanguage{ngerman}±13.2\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.017\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Values are presented as mean \selectlanguage{ngerman}± standard deviation or number
(percentage).

\textbf{Hosted file}

\verb`image1.emf`  available at \url{https://authorea.com/users/451885/articles/550079-accuracy-of-transthoracic-echocardiography-in-diagnosis-of-cardiac-myxoma-single-centre-experience}

\textbf{Fig.1 Panel A.} Transthoracic echocardiography, apical 4-chamber
view. Cardiac mass in left atrium is attached to the interatrial septum
in the region of the fossa ovalis (arrow). Histopathological
characterization confirmed cardiac myxoma. \textbf{Panel B.} Abundant
myxoid stroma with clusters of myxoma cells forming cords and ring
structures (HE 100x). RA -- right atrium, RV -- right ventricle, LA --
left atrium, LV -- left ventricle

\textbf{Hosted file}

\verb`image2.emf`  available at \url{https://authorea.com/users/451885/articles/550079-accuracy-of-transthoracic-echocardiography-in-diagnosis-of-cardiac-myxoma-single-centre-experience}

\textbf{Fig.2} Flow diagram showing the diagnostic accuracy of
preoperative TTE in patients with suspected CM. The predictive value and
accuracy of preoperative TTE was calculated using the results of
pathohistological examination as the gold standard. TP -- true positive;
FN -- false negative; FP -- false positive; TN -- true negative; TTE --
transthoracic echocardiography\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig1/Fig1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig2/Fig2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

