**6. Conclusion and future directions**

Being the most common primary cardiac neoplasm in adults, the present state of research on its set cause, Pathobiology, physiopathology, and pathophysiology are still elusive as clinical and research efforts are being channeled toward its morbidity, mortality and its possible reoccurrence after surgery. If resultant mitral regurgitations and long-term survival for patients is to be achieved as it's the main goal in all neoplastic diseases, a proper understanding of myxomas pathology and the probable underlying process that could occur before and after therapeutic and/or surgical interventions employed is highly essential to tackle the un resolving issue in the field. Management of this condition requires adequate therapeutical background knowledge of the various possible outcomes to allow for an early identification of masked regurgitations caused by the LAM as a result of the probably altered valve motion or damaged valve apparatus in combination with the activated underlying processes involved with a well-planned follow-up regimen as regurgitations in some cases might not be detected immediately after the intraoperative Transesophageal echocardiography is used to check if the myxoma was totally resected and the surgery satisfactory as it could be termed by the physician as a physiological residual regurgitation seen after such kind of surgery which could be detrimental in the long term. However, current clinical features and echocardiographic criteria's are not sufficient enough to detect mitral regurgitations and probable underlying pathological conditions early to achieve an effective medical management and/ or surgical therapy.

The most challenging problem both surgeons and interventionist face is the doubtful nature surrounding possible resultant masked regurgitations with LAM as this could be residual following myxomas resection coupled with the underlying pathological factors aligned with this neoplasm as it propagates the destruction, perforation, elongation, thinning, tethering, thickening, retraction, displacement and ischemic changes seen in mitral valve regurgitation and/ or prolapse. Bearing this in mind, at the slightest suspicion of hemodynamic and architectural change in mitral valve apparatus and ventricular geometry [remodeling] during medical management or surgical intervention, a thorough assessment of the mitral valve apparatus should be made using Transthoracic echocardiography [outpatient settings] and Transesophageal echocardiography [inpatient settings] in combination with the surgeons direct vision assessment if surgery was the treatment of choice irrespective of the known diagnosis [myxoma] in order to rule out any possible concomitant pathology such as coronary embolization to achieve favorable long-term prognosis. Finally, future directions and approaches made by the various scientific communities should be directed toward identifying the key dynamic concepts behind LAM biological, physiological and pathological components, clinical features and the echocardiographic criteria's to be used in an early detection of mitral valve regurgitation and the possible underlying pathological processes and/or complications that could precipitate silent mitral valve insufficiencies after medical management or surgical interventions as this will be an important achievement and a novel contribution to the field.
