Description

A 62-year-old woman was presented to the surgical ward, with severe abdominal pain and vomiting. She had sinus tachycardia (135/min) and her blood pressure was 80/60 mm Hg. The physical examination revealed generalised abdominal distension with signs of peritonitis. Laboratory parameters revealed polymorphonuclear leucocytosis (total leucocyte count of 21 000/mm³ with 88% neutrophils), blood urea nitrogen=74 mg/dL and serum creatinine=2.1 mg/dL. X-ray of the abdomen showed air under the diaphragm. CT angiography revealed absence of contrast beyond the mid segment of the superior mesenteric artery (SMA) (figure 1). A large filling defect was noted in the left atrium (LA) on CT scan (figure 2). Echocardiogram also demonstrated a large 3.1×3.2 cm rounded, mobile mass in the left atrium, which was heterogeneous in echogenicity (figure 3A). It was attached to the interatrial septum in the region of the fossa ovalis. The LA appendage was clear (figure 3B). Neither mitral valve nor left ventricle showed underlying disease. These features were supportive of a diagnosis of cardiac myxoma, instead of a thrombus. Unfortunately, the condition of the patient continued to deteriorate and she succumbed to sepsis. Relatives refused an autopsy, so histopathological diagnosis was not possible. Myxomas are the most common primary tumours of the heart, and are often located in the LA, where they arise mostly from the interatrial septum.1 Embolisation occurs in 30–40% of patients with myxomas, with cerebral arteries being the most common destination. Symptoms related to peripheral embolism are experienced in 2–15% of cases. Cases of mesenteric embolism are extremely rare.2 Retrospective studies have shown that histological cardiac tumour is an independent predictor of an embolic event. Besides myxoma, other tumours with high embolic potential are sarcoma, lipoma and fibroelastoma.3

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Figure 1

CT angiography showing absence of contrast beyond the mid segment of the superior mesenteric artery (arrow).

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Figure 2

CT of the thorax showing a large filling defect in the left atrium (arrow).

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Figure 3

(A) Transthoracic echocardiogram, parasternal short axis view, showing a large 3.1×3.2 cm rounded, heterogeneous echogenic mass in the left atrium. Note that the left atrial appendage is clear (white arrow). (B) Transthoracic echocardiogram, apical four-chamber view, showing the left atrial mass attached to the interatrial septum near the fossa ovalis. AO, aorta; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.