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Mu-Chien Sun, Hui‐Chun Tai, Chien-Hui Lee (2011)
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JSCR 2014; 9 (4 pages) doi:10.1093/jscr/rju093 Case Report Surviving catastrophic disintegration of a large left atrial myxoma: the importance of multi-disciplinary team Louay Habbab , Haifa Alfaraidi and Andre Lamy Division of Cardiac Surgery, Hamilton General Hospital, McMaster University, Hamilton, ON, Canada *Correspondence address. 237 Barton St E, Hamilton, ON, Canada L8L 2X2. Tel: þ1-905-521-2100; E-mail:louay@habbab.com Received 31 July 2014; accepted 14 August 2014 Atrial myxomas are the most common primary cardiac tumors, representing 50% of all benign cardiac tumors. Patients with a left atrial myxoma (LAM) generally present with symptoms of mechanical obstruction of blood flow, systemic emboli or constitutional symptoms. Embolic complications may occur any time with progression of the tumor; therefore, myxoma is usually considered an indication for urgent surgery. This report describes a patient with mobile large LAM who survived multiple emboli to the brain, spleen, kidneys, abdominal aorta and lower limbs during hospitalization for surgery, illustrating the critical nature of this finding and its pos- sible catastrophic complications and demonstrating the importance of multi-disciplinary team in the decision-making process and the management of such complications and supporting the hypothesis that intravenous thrombolysis may be safely used in the treatment of embolic stroke due to cardiac myxoma. INTRODUCTION blood pressure of 130/86 mmHg and a heart rate of 105/min. Clinical examination revealed a mid-diastolic murmur in- Atrial myxomas are the most common primary cardiac creasing on expiration with a grade 2/6 pan systolic murmur tumors, representing 50% of all benign cardiac tumors [1]. located at the sternal border increasing on inspiration and bi- Patients with a left atrial myxoma (LAM) generally present lateral basal crepitations on chest auscultation. Chest X-ray with symptoms of mechanical obstruction of blood flow, sys- showed some atelectasis with right blunting of the costophre- temic emboli or constitutional symptoms [2]. Systemic embol- nic angle. ECG showed sinus rhythm with ST segment depres- ization usually results from necrotic tumor fragments or sions in the lateral leads. thrombi from the surface [2] and rarely from complete tumor Transthoracic echocardiogram (TTE) revealed a 4.8 detachment [3]. This report describes a patient with large 2.5 cm mobile mass arising from the interatrial septum of a se- mobile LAM who survived catastrophic multiple embolization verely dilated left atrium, causing moderate left ventricular to the brain, spleen, kidneys, abdominal aorta and lower inflow obstruction with a mean gradient of 12 mmHg and limbs, illustrating the critical nature of this finding and demon- trace mitral regurgitation (Fig. 1A and B). There was severe strating the importance of multi-disciplinary team in the man- tricuspid regurgitation with a systolic pulmonary artery pres- agement of such complications. sure of 61 mmHg. The patient described symptoms of angina before her current hospitalization for shortness of breath. For that reason, a coronary angiogram was ordered before her CASE REPORT surgery and revealed 80% lesions in the mid-left anterior A 52-year-old female was referred to our hospital with the descending artery and a 70% stenosis at the origin of the pos- terior descending artery of a dominant left circumflex artery. diagnosis of LAM. She had pneumonia 3 months prior to ad- The next morning after her coronary angiogram, the patient mission. The diagnosis of myxoma was made during the workup of shortness of breath that persisted despite the treat- suddenly showed signs of confusion and began to experience slurred speech and left-sided facial droop with left-sided ment of the pneumonia with antibiotics. The patient was a hemiplegia. She was intubated to protect the airway and was heavy smoker. On admission the patient appeared ill with a Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.# The Author 2014. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Page 2 of 4 L. Habbab et al. Figure 1: TTE 4-chamber view during systole (A) and diastole (B) showing a large LAM attached to the interatrial septum and obstructing diastolic filling of the left ventricle and follow-up four-chamber view during systole (C) and diastole (D) showing a marked reduction in the size of the LAM (LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle). sent for an urgent computed tomography (CT) scan of the embolectomies and bilateral aortofemoral bypass surgery. The head, which revealed a hyperdense minute clot lodged at the pathological examination of the emboli confirmed the diagnosis right internal carotid artery bifurcation. Accordingly, tissue of atrial myxoma. plasminogen activator thrombolytic therapy was initiated. A After a stormy postoperative course, the patient was left repeat TTE showed that the mass was markedly decreased in with substantial neurological deficits caused by right hemi- size (2.1 0.9 cm) compared with a previous study, likely sphere damage including dense left-sided hemiplegia, speech due to embolization (Fig. 1C and D). articulation problems and swallowing deficits that required On further examination, her legs were cold and mottled and percutaneous endoscopic gastrostomy tube insertion. Few a CT angiography of the abdomen, pelvis and both lower ex- months later and following intensive medical management tremities revealed occlusion of the distal infra-renal abdomin- that included cranioplasty utilizing the original skull fragment al aorta and iliacs (Fig. 2A and B) and superficial femoral preserved after the craniectomy, the patient was discharged to arteries with weak runoff on the left and no runoff on the right be followed by rehabilitation services and to be evaluated for side (Fig. 2C and D). Multifocal infarcts of the spleen and surgical removal of the remnant of the LAM as soon as her both kidneys were also noticed (Fig. 2A). general condition allows. Repeated CT scan of the head 24 h later confirmed the diagnosis of an evolving large right hemisphere infarction involving both anterior and middle cerebral arteries territory DISCUSSION with midline shift (Fig. 3A and B). Hemicranial decompres- sion was performed and a follow-up CT scan of the head, 24 h This patient represents a typical cardiac myxoma case, occur- later, showed transcranial herniation of the right cerebral ring in a woman between the third and sixth decades of life, hemisphere with reduction of the midline shift (Fig. 3C and D). localized to the left atrium and arising from the interatrial Likewise, because of the multiplicity of the emboli, she also septum, which is the case in 75–90% of the cardiac myxomas developed occlusion of the aorta as well as in both femoral [4]. The patient gave a 3-month history of not feeling well systems and right popliteal artery that required corresponding with persistent SOB and later developed multiple systemic Surviving catastrophic disintegration of a large LAM Page 3 of 4 Figure 2: Sagittal (A) and coronal (B) computed tomographic angiogram images of the abdomen and pelvis and coronal images (C and D) of both lower extrem- ities showing occlusion of the distal infra-renal abdominal aorta (thin arrow) and iliacs (thick arrows) and superficial femoral arteries with weak runoff on the left and no runoff on the right side (angled arrows) with multifocal infarcts of the spleen (S) and left kidney (K). Figure 3: Axial (A and C) and coronal (B and D) CT images of the brain showing a large infarct in the area of the right middle cerebral artery before (A and B) and after (C and D) right hemicranial decompression with transcranial herniation of the right cerebral hemisphere (interrupted curved arrows). Page 4 of 4 L. Habbab et al. embolizations and all these findings are expected with LAM. ous thrombolysis may be safely used in the treatment of Occurring in 67% of the cases, intracardiac mechanical embolic stroke due to cardiac myxoma [6]. obstruction of blood flow is the commonest cause of most presenting symptoms of LAM including dyspnea, palpita- REFERENCES tion, chest discomfort, dizziness and syncope [1, 2]. 1. Reynen K. Cardiac myxomas. N Engl J Med 1995;333:1610–7. Systemic embolization occurs in 30–40% of patients [1, 2], 2. Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac with 50 – 70% of embolic episodes affecting the central myxoma. A series of 112 consecutive cases. Medicine 2001;80:159–72. nervous system [5]. In this report, the patient suddenly rup- 3. Coley C, Lee KR, Steiner M, Thompson CS. Complete embolization of a tured her large mobile LAM and developed multiple emboli left atrial myxoma resulting in acute lower extremity ischemia. Tex Heart Inst J 2005;32:238–40. to the brain, spleen, kidneys, abdominal aorta and lower 4. Aggarwal SK, Barik R, Sarma TC, Iyer VR, Sai V, Mishra J, Voleti CD. limbs. Such presentation illustrates the critical nature of this Clinical presentation and investigation findings in cardiac myxoma: new finding and its possible catastrophic complications and insights from the developing world. Am Heart J 2007;154:102–7. 5. O’Rourke F, Dean N, Mourandian MS, Akhtar N, Shuaib A. Atrial myxoma as a demonstrates the importance of multi-disciplinary team in cause of stroke: case report and discussion. Can Med Assoc J 2003;169:1049–51. the decision-making process and the management of such 6. Sun MC, Tai HC, Lee CH. Intravenous thrombolysis for embolic stroke complications. It also supports the hypothesis that intraven- due to cardiac myxoma. Case Rep Neurol 2011;3:21–6.
Journal of Surgical Case Reports – Oxford University Press
Published: Sep 12, 2014
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