CE: Namrta; JCM/201701; Total nos of Pages: 2;
JCM 201701
Images in cardiovascular medicine
Left atrial myxoma: two sides of the same coin Amedeo Pergolinia, Giordano Zampib, Fabio Sbaragliaa and Francesco Musumecia J Cardiovasc Med 2013, 14:000–000 a
Department of Cardiovascular Science, ‘S. Camillo-Forlanini’ Hospital, Rome and bU.O.C. Cardiologia ed Emodinamica Ospedale Belcolle, Viterbo, Italy
AQ2
Correspondence to Giordano Zampi, Strada Sammartinese s.n.c. Viterbo, Italy Tel: +39 0761 339 424/39 0393 602 237; fax: +39 0761 339 424; e-mail:
[email protected] Received 2 January 2013 Revised 28 February 2013 Accepted 7 April 2013
Presented are two cases of myxoma of the left atrium which greatly differ in terms of symptoms and clinical presentations. The first case is of a 55-year-old Caucasian woman who had been experiencing worsening symptoms of congestive heart failure in the past 2 months. As a result of
progressive dyspnea and peripheral edema, she was admitted to our Emergency Department. Upon arrival, physical examination revealed a mid-diastolic murmur best heard in the left-ventricular area and bibasal rales. A transthoracic echocardiography (TTE) was promptly performed, showing a large mass in the left atrium. A full-body computed tomography (CT) was subsequently performed, confirming the findings of the TTE. The patient was admitted to our Cardiothoracic Surgery Department to remove the mass urgently in order to reduce the risk of thromboembolic phenomena. Intraoperative transesophageal echocardiography (TEE) was performed showing a large mass in the left atrium, adherent to the inter-atrial septum. The mass was homogenous, with internal hyperechoic areas, regular margins and diameters of 5.8 3.8 cm; it occupied a large
Fig. 1
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AQ3 1558-2027 ß 2013 Italian Federation of Cardiology
DOI:10.2459/JCM.0b013e3283621c75
CE: Namrta; JCM/201701; Total nos of Pages: 2;
JCM 201701
AQ1
2 Journal of Cardiovascular Medicine 2013, Vol 00 No 00
Fig. 2
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part of the left atrium, protruding into the left ventricle during diastole (Fig. 1a, c) and causing a functional mitral stenosis (mean transmitral gradient of 8 mmHg) (Fig. 1b, d). The mass was surgically removed with subsequent complete relief of the original symptoms during the postoperative period (Fig. 1e). Histological examination of the surgically removed cardiac mass showed characteristic myxoid cytoplasm of the tumour cells forming abnormal vascular spaces and stroma containing mesenchyme-like cells. The second case is of a 55-year-old Caucasian woman who experienced a sudden cerebrovascular accident, having presented with expressive aphasia. She was promptly admitted to our emergency room, where a brain CT was performed showing a left internal capsular infarction. A routine TTE was performed showing a large irregular mass in the left atrium. When the clinical condition of the patient was stable, the patient was admitted to our Cardiothoracic Surgery Department. A thoraco-abdominal CT scan was performed which excluded secondary lesions. Intraoperative TEE showed a large heterogeneous multilobulated mass in the left atrium originating from the inter-atrial septum, with diameters of 7.5 3 cm (Fig. 2a); moreover a patent
(d)
foramen ovale (PFO) with a small left to right shunt was clearly identified. The mobile mass, with hypoechoic foci, protruded into the left ventricle during diastole (Fig. 2b), causing no obstruction to the ventricle inflow. It was very highly mobile, with a distinctly irregular appearance conferring an increased risk of embolism: in actual fact it also protruded into the right atrium, through the PFO (Fig. 2c, d). The mass was surgically removed (Fig. 2e) and the PFO was closed with a patch. Postsurgical histological examination revealed myxoma cells and neurovascular structures on a background of myxoid matrix. Although the two cases presented were very similar (same age of the patients, both masses originating from the inter-atrial septum, maximum diameter >5 cm; in both cases surgery was performed to remove the mass), the clinical picture was very different according to the morphological features of the myxoma and to the cardiac structures involved, showing the multifaceted presentation of atrial myxoma.1
Reference 1
Angelini GD, Fraser AG, Butchart EG, Henderson AH. A report and review of recurrent left atrial myxoma: not always such ’a benign tumor’. Eur J Cardiothorac Surg 1988; 2:465–468.
