A DRAMATIC PRESENTATION OF A CARDIAC MYXOMA

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiac myxoma is the most frequent primary cardiac neoplasm, nonetheless, the cardiac tumor is very rare.1 The diagnosis of these tumors can be incidental or due to symptoms secondary to complications, like embolization, or valvular dysfunction.2 The management will depend on the size and characteristic of the mass. Embolic stroke is a dramatic and severe complication of cardiac myxoma.2,3 CASE PRESENTATION: A 31 year-old female with a PMHx of well controlled Crohn's disease, presented to our institution via helicopter for a higher level of care, after receiving TPA for an ischemic stroke. A mechanical thrombectomy was planned and her NIHSS was 9. After she arrived, a CT cerebral perfusion scan showed an acute ischemic infarction in the territory of the right MCA with right superior M2 occlusion. There was a mild mass effect on the right lateral ventricle without evidence of brain herniation. The patient was started on NS 3% and mannitol.On the 2nd day of hospitalization the patient suddenly desaturated requiring emergent intubation. A chest x-ray demonstrated flash pulmonary edema. The patient's mechanical ventilation was optimized for ARDS and she was turned prone. On the same day the patient was started on multiple pressors. On day 3 a copious amount of clear fluid was suctioned from the ET tube, analyzed as transudate with no signs of infection.The patient's cerebral edema also worsened and a right decompressive craniectomy was required. The patient began to go into multiorgan failure due to continued hypoperfusion. Her LFTs trended upwards as her kidney function declined. On day 4 an Echocardiogram showed a normal left ventricular size with decreased EF 25%-30%. A large mobile mass was attached to the interatrial septum obstructing the mitral valve with moderate mitral regurgitation and pulmonary hypertension. This mass was suggestive of an atrial myxoma. CT surgery was immediately consulted, intervention was scheduled for the following day. Unfortunately the patient coded the same day after she was turned from prone to supine. Multiple rounds of CPR were performed, however the patient expired. DISCUSSION: We suspect that the change in position caused increased outflow obstruction by the myxoma resulting in cardiac arrest. Due to the large size of the mass and the rapid progression of the patient's symptoms, it is unlikely an early diagnosis would have significantly changed her prognosis. CONCLUSIONS: The severe and dramatic presentation of this case, showed the relevance of this rare pathology and the devastating consequences of the natural course of this disease. In a retrospective analysis of the case, no personal history suggested this diagnosis. In the setting of a sudden ischemic stroke shortly followed or accompanied by flash pulmonary edema, should arouse clinical suspicions for some embolic pathology that may be causing outflow obstruction such as an atrial myxoma. REFERENCE #1: El Sabbagh, Abdallah et al. "Cardiac Myxoma: The Great Mimicker." JACC. Cardiovascular imaging 10.2 (2017): 203–206. Web. REFERENCE #2: Vontobel, Jan, Martin Huellner, and Paul Stolzmann. "Cerebral 'Metastasizing' Cardiac Myxoma." European heart journal 37.21 (2016): 1680–1680. Web. REFERENCE #3: Saddoughi, Sahar A., Joseph J. Maleszewski, and Hartzell V. Schaff. "Cardiac Myxoma: Simplifying a 'Complex' Case." The Journal of thoracic and cardiovascular surgery 152.5 (2016): 1439–1440. Web. DISCLOSURES: No relevant relationships by Javier Cabello Garza, source=Web Response No relevant relationships by Heriberto Cantu, source=Web Response No relevant relationships by Zachary Keatts, source=Web Response No relevant relationships by Ismael Polo Perez, source=Web Response