Recurrent Myxoma Research Articles

Cardiac Myxomas in Carney Complex: Single Institution Multidecade Experience

BackgroundWe present our surgical experience with cardiac myxomas in the setting of Carney complex (CNC). MethodsWe searched our institutional data explorers to identify patients diagnosed with CNC. We gathered clinical, surgical, and recurrence data from electronic medical records. In total, 38 patients with CNC were documented from 1970 through 2023. ResultsCardiac myxomas developed in 24 patients (63.1%) in the setting of CNC. The median age of onset for cardiac myxoma occurrence was 39.0 years (interquartile range [IQR], 25.0-56.0 years). Most patients were females (62.5%), and all underwent surgery. A total of 42 myxomas (52.7%) were extracted from the left atrium, 12 (15.0%) from the right ventricle, 11 (13.7%) from the right atrium, and 6 (7.5%) from the left ventricle. Among the 24 myxoma patients, 13 (54.1%) experienced at least 1 myxoma recurrence. The median time for the first myxoma recurrence was 7.5 years (IQR, 3.8-10.0 years). There were 27 recurrences (52.9%) from the same chamber, 11 (29.4%) from different chambers, and the localizations in 9 (17.6%) were undocumented. The freedom from tumor recurrence was 100% (95% CI, 100%-100%), 66.7% (95% CI, 44.7%-99.5%), and 16.7% (95% CI, 4.7%-59.1%) at 1, 5, and 10 years, respectively. The long-term survival was 100% at 10 and 15 years. ConclusionsCardiac myxomas developed in nearly two-thirds of CNC patients (63.1%) in this study, and more than half (54.1%) experienced recurring instances. Consistent monitoring through echocardiograms is essential for detecting asymptomatic first-time occurrences or recurrences. Surgical removal remains the key treatment method for managing cardiac myxomas associated with CNC.

Abstract 15843: Biatrial and Recurrent Cardiac Myxoma in a Rare Case of Carney Complex

Primary cardiac tumors (CTs) are exceptionally rare, and are predominantly benign masses. Myxomas make up more than 60% of these lesions and most frequently develop in the left atrium (LA), followed by the right atrium (RA). Carney complex (CNC) is a rare, typically autosomal dominant, multiple endocrine neoplasia characterized by cutaneous findings, myxomas, endocrine and/or nonendocrine neoplasms. We report a rare case of CNC involving biatrial and recurrent myxomas. A 36-year-old female presented to Cardiology Clinic at our center for management of CNC. Three years prior, she was evaluated at a local hospital for acute stroke where TTE showed a myxoma (2 x 2 x 2.5cm) attached to the left atrial septum, prompting resection. On followup TTE 2 years later, she had a mass in the LA, prolapsing through the mitral valve into the left ventricle. She underwent resection of the myxoma (2.9 x 3.9 cm) and left atrial appendage, which was complicated by recurrent stroke. She was found to have a PRKAR1A gene mutation (c.97 deletion) suggestive of CNC and was referred to our center. At Cardiology Clinic, she denied chest pain, dyspnea, presyncope, and syncope. Her father and children did not have the gene mutation. Exam revealed lentigines on her lower lip and pigmentation of an inner canthus. She was diagnosed with primary pigmented nodular adrenal disease by Endocrinology. On TEE, she was found to have a recurrent LA mass (1 x 1 x 0.8 cm) attached to the interatrial septum, but no right-to-left atrial shunt. This prompted surgery consultation. Numerous intracardiac myxomas were removed during surgery; one in the LA attached to the septum, 3-4 smaller ones, and one 2 cm myxoma located in the RA. The interatrial septum was also resected given recurrent myxoma in this region. She underwent cryoablation to prevent recurrence and did well post-surgery. CTs, which includes primary CTs and secondary metastatic disease, are uncommon where the former has an incidence of 0.001-0.3%. We presented a case of recurrent and biatrial cardiac myxomas in the setting of CNC, which is seldomly reported in the literature. Taken together, given the rarity of primary CTs, genetic predispositions or syndromes should be considered especially in the setting of recurrence and/or multiple masses.

Role of three-dimensional transesophageal echocardiography in cardiac myxomas: an imaging challenge.

Nowadays, the diagnosis of cardiac myxomas (CM), particularly the histological types, remains a challenge. Two-dimensional (2D) transthoracic (TT) and transesophageal (TEE) echocardiography (ECHO) represent the first steps in the imaging pathway. 3D ECHO, implemented in imaging practice, appears to be an emerging diagnostic technique that overcomes some of the limitations of 2D ECHO while integrating the information provided by magnetic resonance (MRI). However, its role in the imaging arena is still debatable. Analyzing 17 myxomas in 13 patients, the study uncovers a diverse anatomical spectrum. Classical CM morphology is a minority, with most myxomas being sessile and originating from unexpected locations (right ventricular outflow tract and left atrial appendage). Texture and size variations are also noted. Comparing imaging, 2D TEE outperforms 2D TT in visualizing anatomical features, especially attachment types. 3D TEE confirms 2D TT findings and offers more detailed assessments, identifying peduncles missed in four cases by 2D TEE. Two small recurrent myxomas were exclusively detected by 3D TEE, not by 2D TEE or MRI. Two patients have papillary myxomas, one has an embolism. Another patient with a solid myxoma also suffers an embolism, with a clot found at the apex during surgery. Our study showed that CM has a wide anatomical spectrum beyond the typical features, making the diagnosis challenging. Therefore, a multimodality imaging approach is essential for distinguishing CM from other cardiac masses and differentiating myxoma histological types. These findings stress the importance of incorporating 3D ECHO alongside other imaging techniques for a comprehensive evaluation.

Recurrent multi-cameral cardiac myxomas in a child with Carney complex.

Cardiac myxoma is a relatively rare tumour, usually solitary, that occurs primarily in the left atrium of adults, but comprises only 30% of cardiac tumours in children. We recently treated a 12-year-old girl with multiple recurrent myxomas in three cardiac chambers(following surgical resection 3 years earlier). Genomic analysis showed the PKAR1A mutation typical for Carney complex.

Surgery for cardiac myxomas: 12-year experience.

Cardiac myxoma is arare benign cardiac tumor observed in approximately 0.5-1 case per 1 million people per year. The aim of this study is to review our 12-year experience in the surgical treatment of cardiac myxoma with an emphasis on the clinical, pathologic, diagnostic, and surgical features. From January 2010 to December 2022, 90 patients (0.67 %) with cardiac myxomas were surgically treated in our institute. Patients´ demographics, cardiac and surgical medical history, surgical procedures, and pre- and post-operative data were analyzed. The median follow-up time was 76 (1-216) months. The mean age of the patients was 59.4 ± 13.5 years, with a higher prevalence of women. The most common preoperative symptoms were arterial embolism and dyspnea, and 35.6 % of patients were asymptomatic. Only 8.9 % of the patients had systemic and constitutional manifestations. The most common location of cardiac myxoma was in the left atrium, followed by the right atrium. Recurrent myxoma developed in 3 patients (2.7 %), and the mean time of recurrence was 55 ± 19.7. Hospital and long-term mortality were 2.2 % and 15.6 %, respectively. Cardiac myxoma is the most common heart tumor with a low incidence. Surgical excision yields very good short and long-term outcomes with low recurrence rate after surgery, and remains the treatment of choice (Tab. 4, Fig. 2, Ref. 13). Text in PDF www.elis.sk Keywords: cardiac myxoma, cardiac tumor, recurrence, survival.

Pulmonary valve myxoma requiring pulmonary valve replacement: a case report

BackgroundMost cardiac myxomas occur in the atria. Myxomas arising from the heart valves are rare, and there are only a few reports of myxomas arising from the pulmonary valve. Complete resection and prevention of embolization at the time of the first surgery are important to prevent the recurrence of myxomas.Case presentationAn 82-year-old female was scheduled to undergo surgery for a fracture of the right femoral neck. The preoperative echocardiography showed a mass in the right ventricular outflow tract. The mass was 36 × 30 mm in size and entered into the pulmonary artery during systole. Cardiac synchronous computed tomography showed a stalked bifurcated mass near the pulmonary valve, which was suspected to be a myxoma. Surgical findings showed a lumen-occupying tumor when the main pulmonary artery was incised. Since the tumor was a single mass with a stalk on the pulmonary valve (right and left pulmonary valve cusps), tumor resection and pulmonary valve replacement (bioprosthetic valve) were performed. A right prosthetic femoral head insertion was performed on postoperative day 36, and the patient was transferred to the hospital on postoperative day 44. However, 1 year later, the patient developed a large myxoma (recurrence) that completely occluded the right pulmonary artery and died of right heart failure.ConclusionsWe report the case of a patient with a very rare myxoma arising from the pulmonary valve, which was treated with tumor resection and pulmonary valve replacement surgery; however, the patient developed another myxoma 12 months later and this tumor was larger than the primary tumor. The surgical margins were indistinct, and there was a high possibility of residual tumor in the pulmonary artery wall; hence, an extended resection should have been considered. The recurrence of myxoma, in this case, suggests that it is important to completely resect the primary tumor during the first surgery and to prevent intraoperative embolization.

A Case Presentation Based on Incidental Diagnosis of Atrial Myxoma in a Patient Presenting With Atrial Fibrillation and Suspected Carney Complex

We present the case of a 54-year-old lady who presented to hospital with palpitations and was diagnosed with atrial fibrillation with rapid ventricular response. She was given intravenous metoprolol 5 mg initially followed by a further 5 mg and was commenced on bisoprolol 2.5 mg once daily. She reverted back to normal sinus rhythm and was referred for echocardiography following an episode of paroxysmal atrial fibrillation. The echocardiogram showed a large mobile atrial myxoma in the left atrium and mild-to-moderate mitral regurgitation with preserved left ventricular function. Her past medical history includes transsphenoidal surgery for acromegaly in 1979, followed by radiotherapy and partial thyroidectomy for goitre. Her chest radiograph was normal and blood results were unremarkable. She was accepted for inpatient transfer to a cardiothoracic centre for surgical removal of atrial myxoma. She underwent surgery with successful excision of the atrial myxoma, and biopsies confirmed the mass to be atrial myxoma. The surgery was complicated by the patient developing atrial fibrillation with fast ventricular response that was chemically cardioverted with an intravenous loading dose of amiodarone 300 mg over 2 hours followed by 900 mg infusion over 24 hours. She had follow-up in the outpatient clinic with cardiology and endocrine specialists for a year and no recurrence of myxoma was noted. Her blood tests including growth hormone and thyroid function tests were normal.

Role of Transesophageal Echocardiography in the Recurrent Biatrial Myxoma of Uncommon Origin

After surgical excision of myxoma recurrence usually happens adjacent to the initial origin site. We report a case of recurrent myxomas in a young male patient that had biatrial recurrence with one tumor originating very unusually from the base of the anterior mitral leaflet. Intraoperative transesophageal echocardiography was instrumental in localizing the site of the origin of left atrial myxoma from the base of the anterior mitral leaflet and in detecting an additional myxoma attached to the wall of the right atrium.

Surgical treatment of primary cardiac tumors: 20-year single center experience.

IntroductionPrimary cardiac tumors are a rare condition presenting with a variety of symptoms. The outcomes of their surgical treatment in the modern era from central Europe have not been recently reported.AimTo evaluate the short- and long-term outcomes of the cardiac tumor operations at our department throughout the last 20 years.Material and methodsThis was a retrospective analysis of all primary cardiac tumor operations performed at our institution between 2000 and 2020. Perioperative data were extracted from patient records. Long-term data were provided by the National Registry of Cardiac Surgery.ResultsSixty procedures for primary cardiac tumor were performed throughout the study period. The most common type of tumor was myxoma (88%), followed by fibroelastoma (8%), lipoma (2%) and sarcoma (2%). There were 2 perioperative deaths (3%). The most common perioperative complication was atrial fibrillation (47%). One (2%) patient underwent reoperation 6 years later because of myxoma recurrence. We recorded 13 long-term deaths, but only 1 patient died as a consequence of cardiac tumor (sarcoma) 15 months after the surgery. Long-term survival of the cohort was comparable with the age- and sex-matched general population up to 15 years postoperatively (relative survival 0.91, CI 0.68–1.23). Rich histopathological illustrations are provided in the online supplementary material.ConclusionsSurgical resection is the standard treatment of primary cardiac tumors. The outcomes of benign tumors are excellent and the long-term postoperative survival is comparable with the general population. The prognosis of malignant tumors remains poor.

Abstract 17116: Recurrent Atrial Myxomas As A Presenting Feature Of Carney Complex

Case Presentation: A 24-year-old man with a history of adrenal insufficiency on hydrocortisone presented to the hospital after losing consciousness in a swimming pool and was found to have an acute MCA stroke. PMHx was significant for left atrial myxoma status post resection 3 years ago, known L frontal brain, L adrenal, and testicular masses status post-resection. His father had a history of resected left atrial mass. Cardiology was consulted for a L atrial mass on the bedside echocardiogram upon initial emergency evaluation, during which the patient was placed on mechanical ventilation with stable vitals. The cardiovascular exam revealed a midsternal scar but was otherwise normal. Pulses were 2+ bilaterally on the upper and lower extremities. The skin was noted to have multiple hyperpigmented macules resembling cafe-au lait spots. The patient underwent mechanical thrombectomy with thrombolysis for his large MCA occlusion. His postoperative course was complicated by a worsening neuro exam in the setting of mid-line shift for which he had undergone decompressive hemicraniectomy. His adrenal insufficiency was managed by endocrinology. A TTE was significant for a L atrial mass measuring 4.8 cm attached to the interatrial septum with a stalk. A CT scan identified 2 discrete hypodensities of 8 mm and 3.8 cm which were thought to be the cardioembolic source for the stroke. An abdominal CT revealed a recurrent L adrenal neoplasm with absent R adrenal gland post resection of neoplasm. Conservative cardiac management was elected in the setting of a worsening neuroprognosis with follow-up post neurologic insult. Discussion: Considering the constellation of neoplastic and cutaneous findings, this was diagnosed as a case of Carney complex. This case identifies recurrent myxoma as a unique feature of Carney complex, ruling out other differentials such as neurofibromatosis and MEN syndrome. It highlights the importance of screening to prevent embolic stroke from recurrent myxomas.

Totally thoracoscopic surgery for treating left atrial myxoma.

We aimed to summarize the experience of totally thoracoscopic surgery for left atrial myxoma, together with analyzing the safety and feasibility. We retrospectively analyzed the clinical data of 15 patients with left atrial myxoma admitted to our hospital from October 2016 to October 2018. The auxiliary hole was located at the midline of the 5th intercostal space of the right chest. The endoscope hole was located at the front position of the fourth intercostal space. Specimens were sent to the pathology department for pathological examination. All the procedures were completed successfully. Extracorporeal circulation time was 46.5 ± 18.6 minute, cross-clamping time was 20.6 ± 6.7 minute, thoracic drainage fluid was 89+60.2 ml, ventilator assist time was 4.3 ± 2.6 hour, intensive care unit stay time was 14.5 ± 4.2 hour, the average postoperative hospital stay was 5.2 ± 1.2 day. There was no death, or red blood cell transfusion during and after surgery. No postoperative complications were reported by the patients. No recurrence of myxoma, residual shunt in the atrial septum and valvular lesions were found after 3months of postoperative cardiac ultrasound examination. Total thoracoscopic surgery for left atrial myxoma was less invasive with satisfactory cosmetic appearance with feasibility and safety. Besides, it caused no serious complications.

Diagnosis of Carney complex following multiple recurrent cardiac myxomas

Carney complex is a rare syndrome caused by a genetic mutation leading to multiple endocrine abnormalities and a variety of tumors. Here, we report a case of Carney complex diagnosed due to recurrent multiple myxomas in the right atrium of a patient 16 years after the resection of the primary left atrial myxoma. Surgical excision was performed for the multiple recurrent right atrial tumors under cardiopulmonary bypass. The patient remained complication-free after surgery and was discharged on the 14th day. He was scheduled to continue echocardiographic follow-up and periodic systemic review by an endocrinologist. This case emphasizes the fact that if cardiac myxomas tend to be multiple and recurrent at a relatively young age, the possibility of Carney complex should be considered, even in the absence of any other related feature other than cardiac tumors.

Surgical Treatment of Heart Mixomas: the Analysis of 10 Years’ Experience

Introduction. Primary cardiac tumors are rare, and the autopsy detection rate does not exceed 0.003%. Approximately 80% of primary heart tumors are benign, 50% of them are myxomas. Diagnosis of cardiac tumors at present in the presence of transesophageal echocardiography is not difficult in most cases. Surgical treatment of mixomas became possible after the introduction of open-heart surgery under cardiopulmonary bypass into clinical practice. After verification of the tumor, its surgical removal is indicated. In the practice of large cardiac surgery clinics, the experience of radical treatment of heart neoplasms is relatively small; therefore, the analysis of tactical approaches and results of operations in this pathology is of absolute interest.Aim of study. To present an analysis of 10 years’ experience in surgical treatment of cardiac mixomas. Material and methods The results of treatment of 58 patients with myxomas who underwent surgical removal of the neoplasm of the heart are presented.Results. Hospital mortality after surgical removal of myxoma was 1.7%, 1 patient died. All patients, we have the long-term period data about, noted a significant improvement in well-being, a decrease or disappearance of dyspnea at rest and/or during exertion, and no recurrence of myxoma was noted. Conclusion. The data obtained indicate, on the whole, good immediate results and high quality of life of patients in the long-term period operated on for heart mixomas.

Case Reports of Left Atrial Myxoma in Elderly and Children

Introduction: Cardiac myxoma is a rare heart disease. Cardiac myxoma can manifest in both intracardiac and extracardiac. This report describes the importance of a careful history taking, physical examination, echocardiography, and complete surgical resection for the management of atrial myxoma in two patients. Case Reports: We reported two cases: a 64 years old female and a 16 years old male with neurological deficit as the chief complaint. The two patients underwent brain imaging and echocardiography evaluation. Both were diagnosed with left atrial myxoma and brain infarction. Surgical resection of the left atrial myxoma was successfully done in both patients and afterward, both were being monitored in the outpatient clinic. During follow up, a gradual clinical improvement can be seen in the right extremities. Echocardiography examination was conducted at 1 month, 3 months, and 6 months follow-ups for both patients and no abnormalities were found. Discussion: Atrial myxomas are the most common primary cardiac tumors. Systemic embolization in atrial myxoma is uncommon manifest as neurological deficit with reported incidence around 20-35%. On the other hand, in stroke or transient ischemic attack patients, atrial myxoma were found in 1 out of 250 young adults and 1 out of 750 older patients. Transthoracic echocardiography (TTE) has up to 95% sensitivity on diagnosing atrial myxoma. The long-term prognosis of the patients when diagnosed and managed correctly is very good and surgery is curative with recurrence rate 1-3%. The patients in our case reports showed gradual clinical improvement with no sign of myxoma recurrence during follow up. Conclusion: Stroke is one of the extracardiac manifestations of atrial myxoma. Thus, it is crucial to evaluate the presence of atrial myxoma in stroke patients. The use of TTE is important in diagnosing atrial myxoma. Resection of atrial myxomas is curative with excellent long-term prognosis and low chance of recurrences.

Reccurent Cardiac Myxoma Treated with Cardiac Transplantation: A Case Report

<h3>Introduction</h3> Cardiac myxoma is the most common type of primary cardiac tumor. Typical clinical features are signals of mitral valve obstruction (dizziness, syncope and pulmonary congestion), constitutional symptoms and systemic embolization. Definitive treatment is surgical excision with favorable outcomes described. However, despite benign nature, myxoma recurrence has been reported in 2 -7% of cases. Cardiac transplantation (CT) is a modality of treatment rarely required for cardiac tumors, especially myxomas. <h3>Case Report</h3> We report a case of a 38-year-old woman, who discovered a cardiac myxoma in a diagnostic work-up after an ischemic stroke. She was submitted to surgical excisions in 1997, 1999 and 2013. Afternsecond surgery, she developed an atrioventricular block and required a definitive pacemaker. She had no family history of cardiac myxomas, neither signals of Carney complex. She was referred to our service for heart transplantation evaluation due to a forth myxoma recurrence. Chief complaint was severe dyspnea with symptoms at rest and physical examination was remarkable due to a grade 3 systolic murmur at the apex. Last transthoracic echocardiogram showed two large masses, one adhered to mitral valve ventricular side and the other fixed at the left ventricular apex extending through entire lateral wall and reaching left ventricular outflow tract (LVOT). Tumor was considered inoperable, and patient was listed for CT on August 4, 2020. Due to rapid tumor growth causing a drop on ejection fraction (EF of 40%) and invasion in LVOT, she was put on priority status and was submitted to CT on September 28, 2020. Surgery and post-operative course were uneventful and patient is well. <h3>Summary</h3> CT is the definitive treatment for refractory cardiovascular diseases from different etiologies. Despite considered benign, in rare cases, myxomas may recur after initial excision and progress to severe disease. This case report adds this scanty field in literature with one patient, which required CT with favorable short-term outcomes.

A SHORT RECURRENCE TIME OF LEFT ATRIAL MYXOMA: CASE REPORT AND LITERATURE REVIEW

Background: Recurrence of sporadic cardiac myxoma remains unusual but the seriousness of the situation justifies the realization of a surgical resection as complete as possible with post-operative clinical and echocargdiographic monitoring. Case presentation: We recall the case of myxoma of the left atriumin a 64-year-old women complicated by functional mitral stenosis and heart failure. She underwent urgent heart surgery, during which a friable tumor attached by a sessile base to the anterior atrial septum was removed. The postoperative effects were complicated by a pulmonary embolism. Eight months later, the patient consulted for exertional dyspnea with an echocardiographic image in favor of a recurrence of myxoma of the left atrium. Conclusion: Several mechanisms have been proposed to explain such recurrence, the most avoidable remain incomplete surgical resection and Implantation of embolic fragments of the original tumor in the myocardium due to a previous surgery.

Primary delayed growth of the right and left atrial myxoma

There is more than 58-year experience of surgical treatment of patients with intracardiac myxomas at the Petrovsky National Research Center of Surgery. Primary delayed growth of the right and left atrial myxoma after 21 years and 5 months was observed only in 1 (0.36%) patient. Transthoracic echocardiography was used for diagnosis of tumors. Tumors were totally resected including adjacent parts of myocardium or subendocardial tissue with subsequent cautery. In-hospital mortality was absent. There were no recurrent myxomas throughout subsequent 10-year follow-up.

P860 Multimodality imaging of multiple recurrent myxomas: the role of three dimensional echocardiography

Abstract A 33-year-old lady who underwent left atrial myxoma resection was found to have on a 3 years follow up transthoracic echocardiography (E) a multilobular mass in the right atrium. A 2D transesophageal echocardiogram (TEE) was performed. Two Multi-lobulated masses were seen in the right atrium(RA); one bigger attached by a peduncle to the atrial wall in between the interatrial septum (IAS) and the superior vena cava and one smaller attached to the inferior RA wall; a remnant likely a suture was seen on the right side of the fossa ovalis; another small mass was noted on the left atrial (LA) side of the IAS; a small mass attached close to the posteromedial commissure and P3 scallop of the mitral valve was also detected. The RA mass was partially protruding into the tricuspid valve during diastole with no significant obstruction to flow. Three dimensional TEE allows an anatomical imaging able to identify the peduncles of two right atrial masses and three LA masses that were confirmed at surgery and consistent with cardiac myxoma at histopathology : one close the previous resection area, one at the opening of the LAA (panel A, white arrow) and one close to the posterior commissure of mitral valve (panel B, yellow arrow) and that were not seen by 2D. Magnetic resonance imaging (MRI) with contrast identified and showed opacification of : two masses in the RA with the pedicles ; - one mass on the LA side of interatrial septum; - one mass close to mitral valve posterior commissure ; however it was not able to detect the small mass close to the LAA. In our case 2D Echocardiography and MRI were able to identify 4 of the 5 recurrences found at surgery. 3D TEE was the only technique able to identify all 5 lesions. MRI is considered the gold standard for detecting cardiac tumor masses; however, even after careful review, it was not possible to identify the presence of the mass close to LAA. In particular 3D TEE was able to image the left atrial masses by an "en face view" of the left atrium from above. In addition, the unique 2D planes in unconventional views allow a more clear identifications of the peduncles of the masses in the right atrium. The identification of the peduncles is mainstay for the diagnosis of recurrent myxomas and exclude other tumors like metastasis or sarcomas. In fact multiple recurrence are very rare in particular if we consider that are in the two atria. Genetic tests for Carney complex were negative. The MRI allowed to confirm the vascularization of the contrast and to identify the peduncles of two masses in the right atrium. A multimodality imaging is able to correctly detect recurrent myxomas by identifying the anatomical features and the vascularization and lead to the diagnosis ; 3DE was the only technique able to correctly identify all the recurrent myxomas and and its use has the potential for being considered the key adjunctive modality for the anatomy when advanced surgical plan is required. Abstract P860 Figure.

A Giant Right Atrial Myxoma with Blood Supply from the Left and Right Coronary Arteries: Once in a Blue Moon

Cardiac myxomas, the commonest primary benign cardiac tumors, are extremely rare, with an incidence ranging from 0.0017 to 0.19% and only about one-fifth of them originating from the right chambers of the heart. A 60-year-old woman was admitted because of recurrent attacks of chest tightness and shortness of breath. Transthoracic echocardiography detected a giant mass in the right atrium; myxoma was indicated by [18F]fluorodeoxyglucose PET/CT. Preoperative selective coronary angiography was performed to assess the extent and severity of coronary stenosis, and showed a strongly neovascularized right atrial mass supplied by two feeding vessels with multiple branches from the left and right coronary arteries. The myxoma was successfully excised with open heart surgery and the patient was free of myxoma recurrence during the 3-year follow-up.

35. A referred case of probable PMR with a different outcome

IntroductionThis is the case of a 67-year-old woman who presented to the rheumatology clinic with suspected diagnosis of polymyalgia rheumatica on prednisolone with complaints of flu-like illness, muscle aches and occasionally low-grade fever. Initial investigation showed anaemia with a significantly raised CRP and ESR. Further investigation revealed a different outcome.Case descriptionA 67-year-old woman presented to the rheumatology clinic with the suspected diagnosis of polymyalgia rheumatica with prednisolone commenced in primary care. Three months before, she presented in primary care with a flu-like illness, muscle aches and occasionally low-grade fever. On investigation, she was found to have anaemia (Hb 92 gm/dl with MCV of 109 femtoliters per cell) with a significantly raised ESR of 123 mm/hr and CRP of 258 mg/L. Initially, there was a history of mild weight loss which she attributed to her diet and subsequently, she regained weight.Her symptoms were not typical of PMR and upon further questioning, she complained of shortness of breath on inclines. She denied any symptoms of dizziness or any symptoms suggestive of embolic manifestation. Her previous medical history includes hypertension and hyperlipidemia for which she was on bendroflumethiazide and statins which were stopped in primary care three months back. Her blood pressure in the clinic was 156/77mmHg with a pulse of 82 beats per minute. There was no clubbing or any signs suggestive of polymyalgia rheumatica or any other connective tissue disease. On auscultation of heart, the first heart sound was loud and the chest was clear. Abdominal and neurological examination was unremarkable. Rest of investigations including urea and electrolytes, liver function test, ANA, anti ENA, Complement C3 &C4, immunoglobulins, creatine kinase, ferritin and thyroid function tests were unremarkable. An echocardiogram was requested as workup of unexplained raised inflammatory markers and non-resolving symptoms which showed a large echogenic mass in the left atrium attached to atrial septum and prolapsing through the mitral valve into the left ventricle, suggestive of left atrial myxoma. She was referred to cardiothoracic surgeons for resection. Her aches and pains subsided and she is doing very well after surgery. DiscussionMyxomas account for 40-50% of primary cardiac tumours. 75-85% occur in the left atrial cavity and up to 25% in the right atrium. Symptoms range from nonspecific and constitutional to sudden cardiac death. In 20% of cases, atrial myxoma may be asymptomatic and reported as an incidental finding. Other reported symptoms are exertional dyspnoea (75%) which may get worse leading to pulmonary oedema. Other symptoms may be due to obstruction of mitral valve leading to dizziness (20%), Symptoms of right heart failure, embolization to the central nervous system and retinal artery involvement may lead to blindness, coronary artery disease, and PE. Constitutional symptoms include fever, weight loss, arthralgias, and Raynaud’s phenomenon and are observed in 50% of patients, 15% of the atrial myxoma patients present with hemoptysis which may be due to an infraction or pulmonary oedema.Laboratory studies include raised inflammatory markers including ESR and CRP, leukocytosis and anaemia. Transesophageal echocardiography has better specificity and 100% sensitivity compared to transthoracic echocardiography.Histologic studies demonstrate the presence of lipidic cells embedded in a vascular myxoid stroma. Other investigation modalities include MRI, CT, and nuclear imaging.Conventional treatment of atrial myxoma is surgical removal by median sternotomy. Mini thoracotomy with robotically assisted surgery has been reported, resulting in a shorter length of hospital stay, and it is considered a safe and feasible method for atrial myxoma excision. The investigators did not observe any difference in the quality of life between the two strategies. A case report of total endoscopic robotic resection of a left atrial myxoma in an elderly patient with persistent left superior vena cava also demonstrated the good outcome. No recurrence of myxoma was observed during the 2-year follow-up period if resected completely.Key learning pointsPolymyalgia rheumatica, raised inflammatory markers, malignancy, atrial myxoma, large vessel vasculitis.Conflicts of interestThe authors have declared no conflicts of interest.