AFFAIRS OF THE HEART: ATRIAL MYXOMA PRESENTING AS EMBOLIC PHENOMENA

Abstract

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Atrial myxomas account for 50% of all cardiac tumors with the majority located in the left atrium. Though it is a benign tumor, it can result in embolic phenomenon with neurological sequelae. Approximately 35% of all left atrial myxomas result in embolization. CASE PRESENTATION: 59 year-old healthy female presented with sudden onset left-sided weakness and paraesthesia. Physical exam was significant for non-palpable right radial pulse, femoral and dorsalis pedis pulses bilaterally. She had decreased sensation and strength in her left arm and leg. No abnormal heart sounds were noted. EKG showed sinus rhythm. CT perfusion head/neck showed matched defects in the right frontal lobe and left cerebellum, with smaller mismatched defect in the right parietal lobe. CTA chest/abdomen/pelvis showed occlusion of the proximal right subclavian artery, distal abdominal aorta at the aortic bifurcation extending into the common iliac arteries, likely related to thromboembolic phenomenon. A hypodense filling defect in the left atrium worrisome for thrombus was also noted. She was deemed to not be a candidate for thrombolysis when assessed by neurology. Discussions between neurology, vascular surgery and cardiology yielded an unanimous decision to start anticoagulation and she underwent emergency revascularization of the right arm and distal extremities. Vascular surgeon also removed myxomatous material from all aforementioned vessels, confirmed by pathology. Echocardiogram showed a 5 cm mobile left atrial myxoma that protruded through the mitral valve into the left ventricular cavity in the diastole. Angiography revealed no coronary disease. Her atrial myxoma was then successfully resected by cardiothoracic surgery. On discharge, she had minimal residual left upper extremity weakness. DISCUSSION: Cardiac myxomas develop in the left atrium, most originating from the atrial septum near the fossa ovalis. Myxomas can present at any age group but occurs more often between the 3rd and 6th decades of life, and commonly in females. Embolization is considered a common manifestation of cardiac myxomas, as seen in the case presented. Other clinical features which are important to consider include constitutional symptoms, heart failure due to tumor obstruction, valve regurgitation and rarely heart block due to invasion of myocardium. Echocardiography is helpful in identifying the presence of a mass and its mobility. Patients with smaller tumors, minimal symptomatology, and no evidence of mitral regurgitation have a high risk of embolism. After diagnosis, surgery should be done in a timely manner to prevent complications such as embolic events or obstruction of the mitral orifice. CONCLUSIONS: Multivessel embolization is common in atrial myxoma especially when it’s located in the left atrium. Echocardiography is essential for diagnosis. Timely surgical evaluation and resection is the cornerstone of management. Reference #1: Braghadeeswar Thyagarajan et al. Extracardiac manifestations of atrial myxomas. J Saudi Heart Assoc. 2017 Jan; 29(1): 37–43. doi: 10.1016/j.jsha.2016.07.003. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5247297/ Reference #2: Akhtar J, Wasay M, Rauf J Atrial myxoma: a rare cause of cardioembolic stroke Case Reports 2012;2012:bcr2012006176. https://casereports.bmj.com/content/2012/bcr.2012.006176 Reference #3: Boutayeb A, Mahfoudi L, Moughil S. Atrial Myxoma: From Diagnosis to Management. Clin Surg. 2017; 2: 1498. http://www.clinicsinsurgery.com/pdfs_folder/cis-v2-id1498.pdf DISCLOSURES: No relevant relationships by Huda Al-Bahadili, source=Web Response No relevant relationships by Krystal Alexander, source=Web Response No relevant relationships by Jakemia Coleman, source=Web Response No relevant relationships by Nirvi Shah, source=Web Response