Investigations Laboratory Studies These are nonspecific Abnormal findings may include elevated erythrocyte sedimentation rate, C-reactive protein, hypergammaglobulinemia, thrombocytosis, thrombocytopenia, polycythemia, leukocytosis, and anemia Electrocardiography The electrocardiogram may also be nonspecific All types of disturbances of rhythm and conduction, and abnormalities of voltage and the ST-T segments, may be seen.1,20 The electrocardiogram may also display the typical pattern of atrial dilation or ventricular hypertrophy.1,15 Incidental low-voltage complexes may be registered, indicating possible pericardial involvement Occasionally, it is possible to find the pattern of ventricular preexcitation.1,5 This is particularly the case when the accessory muscular atrioventricular pathways are composed of the intracardiac tumor.32,33 Chest Radiography Cardiac tumors may alter the contours of the heart, but the changes in themselves are most often nonspecific The cardiac contour may be normal or may display enlargement of either the entire heart or any particular chamber.34–36 Gross and bizarre distortions of the cardiac contour occasionally occur that are then suggestive of a tumor The overall picture may be further complicated by the presence of pericardial fluid Radiographic signs of pulmonary venous obstruction with left atrial enlargement may be observed in patients with obstructive left-sided tumors Calcification of a primary tumor may occasionally be so intense that it can be noted on the chest radiograph (Fig 52.5).34,35 FIG 52.5 Extensively calcified right atrial myxoma from an adult heart Inset, Postmortem radiograph Calcification of this extent was also seen on chest radiographs during life Echocardiography Echocardiography is universally established as the first-line and main diagnostic modality for tumor assessment Transthoracic echocardiography is highly portable and ubiquitous, with very high spatial and temporal resolution It allows for accurate determination of the size, shape, texture, location, attachment, mobility, and hemodynamic consequences of the tumor Echocardiography gives information as to whether the tumor is encapsulated and whether it is solid or cystic.37 Texture may be inferred by the grayscale appearance, although interpretation remains subjective.38 Color flow mapping has been applied to distinguish tumor mass from endocardium.39,40 Three-dimensional echocardiography may allow for improved visualization of morphologic and spatial characteristics of cardiac and paracardiac tumors, establishing their relationships with adjacent structures, and in certain cases may be superior to transthoracic echocardiography in the evaluation of the size of intracardiac masses (Fig 52.6).41–45 FIG 52.6 Dynamic three-dimensional echocardiography showing a myxoma in a 12-year-old boy, originating in the left atrium and attached to the atrial septum in the region of the oval fossa The tumor is protruding into the atrioventricular orifice during ventricular diastole (Courtesy Dr Jan Marek, Great Ormond Street Hospital, London, United Kingdom.) Transesophageal echocardiography can be a useful adjunct to transthoracic imaging, notably in patients with suboptimal transthoracic windows In such patients it is ideally suited for the examination of posterior structures such as the atriums, interatrial septum, caval veins, and atrioventricular valves.46 Another important application is the differentiation of true pathology from normal, or variants of normal, anatomy such as the terminal crest of the right atrium In addition, transesophageal two- and three-dimensional imaging can be used intraoperatively to assist with surgical excision of cardiac tumors or to guide transvenous biopsy.3,47 The diagnostic sensitivity of transthoracic and transesophageal approaches has been reported to be 93.3% and 96.8%, respectively.48 The sensitivity is greatest for endocardial lesions, where the contrast between tumor and an echolucent cavity is most apparent, permitting characterization of the size and mobility of the masses In contrast, echocardiographic assessment of the pericardial tumors may be more limited due to their frequent position in the echocardiographic far