<Brief
History>
A 59-year-old woman was admitted due to progressively
exertional dyspnea for two months. The patient had been well
until six months before admission, when she had mild dyspnea
on exertion and got fatigue easily. There was no chest pain
but mild palpitation during dyspnea attack. The dyspnea
relieved after a short period of rest. In recent two months,
the exertional dyspnea progressed and her exertional capacity
was significantly limited. There was no fever, weight loss,
dizziness, or airway symptoms in recent 6 months. Tracing back
her past medical history, there were no cardiac or pulmonary
disease were diagnosed.
On physical examination, her blood pressure was 132/68 mmHg
and her respiratory rate was 22/min. Neither lymph node
enlargement nor jugular vein enlargement was noted on the
neck. Her breathing sound was clear. In cardiac auscultation,
the rhythm was irregularly irregular with loud and widely
split S1; an early diastolic sound was identified. A grade
III/VI holosystolic murmur and Gr II/VI diastolic murmur were
noted over apex. The abdomen was soft and bowel sound was
normoactive. The extremities were freely movable without
significant edema or cyanosis.
In electrocardiogram, atrial fibrillation with a
ventricular rate of 76 per minute was identified. Neither q
wave nor significant ST-T change was noted. Chest
roentgenogram revealed borderline heart size without pulmonary
lesions. The laboratory data were shown in
table 1.
A transthoracic echocardiography was
performed to evaluate her heart function. A 4.5*2.15 cm
oscillating mass attaching on interatrial septum (IAS) was
identified in left atrium (LA). (Figure
1) In magnate resonance image, the LA mass was isointese
in T1 and mild hyperintence in T2. A diagnosis of myxoma was
made according to her clinical course, physical finding and
image studies. Coronary angiography showed patent coronary
artery and identified right coronary artery as the tumor
supplying vessel. (Figure
2) Furthermore, the tumor was noted as a filling defect in
levophase of pulmonary angiogram. (Figure
3
) The patient received tumor excision on the next day
smoothly. The pathology proved the clinical diagnosis of
myxoma. She was discharged smoothly two weeks after operation,
and remained asymptomatic in 6-month follow-up.
<Discussion>
Primary tumors of the heart are rare. Three quarters of the
tumors are benign, and half the benign heart tumors are
myxomas. The mean age of patients with sporatic myxomas is 56
years, and 70 percent of them were female. About 86% of myxoma
occur in LA and more than 90% are solitary. Myxoma can also
occur in the right atrium and, less often, in the right and
left ventricle (3-4% each). The usual site of attachment of LA
myxoma is in the area of fossa ovalis (90%). The other
attaching site included anterior, posterior wall, and
appendage (10%); mitral and tricuspid valves, although rarely,
had been reported.
The clinical features of myxomas are determined by their
location, size, and mobility. Most patients present with one
or more of the triad of embolism (occur in 30-40% of myxoma
patients), intracardiac obstruction, and constitutional
symptoms. Occasionally, there are no symptoms, particularly
with small tumors. The symptoms and sign of intracardiac
obstruction mimic the clinical picture of mitral or tricuspid
valve stenosis. The extent of valvular obstruction may vary
with body position. If the tumor is large enough, temporary
complete obstruction of the orifice of the mitral or tricuspid
valve may occur, resulting in syncope or sudden death.
Constitutional disturbances included fatigue, fever,
erythematous rash, arthralgia, myalgia, and weight loss. The
laboratory abnormalities included anemia (sometimes
polycythemia), and elevations in the erythrocyte sedimentation
rate and the serum C-reactive protein, globulin, and serum
interleukin-6 levels.
The diagnosis depends on image studies. Transthoracic
echocardiography can generally be used to determine the
location, size, shape, attachment, and mobility of a myxoma.
Transesophageal echocardiography (TEE) provides unimpeded
visualization of the atria, atrial septum, and is therefore
particularly helpful in detecting the site of insertion. Other
image studies, like computed tomography or magnate resonance
image, can differentiate tissue composition. It makes possible
to identify solid, liquid, hemorrhagic, and fatty,
space-occupying tumors.
The treatment of choice for myxomas is surgical removal and
it is usually curative. After the diagnosis has been
established, surgery should be performed promptly because of
the possibility of embolic complications or sudden death. The
short- and long-term prognosis is excellent; the rate of
operative mortality was 0 to 3 percent. Recurrence of sporatic
myxomas is only 1 to 3 percent for sporadic tumors. Incomplete
resection is thought to be the reason for a recurrence.
Table 1. Laboratory
data
[ CBC+PLT ]
WBC |
RBC |
HB |
HCT |
MCV |
MCH |
MCHC |
PLT |
K/μL |
M/μL |
g/dL |
% |
fL |
pg |
g/Dl |
K/μL |
5.42 |
4.43 |
13.5 |
40.7 |
91.9 |
30.5 |
33.2 |
332.0 |
Seg |
Eos |
Baso |
Mono |
Lym |
% |
% |
% |
% |
% |
69.2 |
0.3 |
0.2 |
5.3 |
25.0 | [ Biochemistry ]
ALB |
GLO |
BUN |
CRE |
T-BIL |
AST |
GLU |
mg/dl |
mg/dl |
mg/dl |
mg/dl |
mg/dl |
U/l |
mg/dl |
4.6 |
3.8 |
10.5 |
1.1 |
0.8 |
23.0 |
103.0 |
Na |
K |
Cl |
Ca |
Mg |
Mmmole/l |
mmole/l |
mmole/l |
mmole/l |
mmole/l |
145.0 |
4.7 |
110.0 |
1.97 |
0.8 |
[ Serology ]
C-reactive protein: 2.7 mg/dl
Figure legends
Figure
1. Five chamber view of transthoracic echocardiography. A
4.5*2.15 mass was noted in left atrium.
Figure
2. Coronary angiogram (right coronary artery). A feeding
artery (black arrow) was branched from right coronary artery
and supplied the myxoma (white arrow).
Figure
3. Pulmonary angiogram. In the levophase of pulmonary
angiogram, a mobile filling defect (white arrow) was noted in
left atrium.
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