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Large left atrial myxoma with an unusual origin
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  1. Rebecca Dobson1,
  2. Emma Tweddle2,
  3. Martha Scott2,
  4. Arzu Cubukcu2
  1. 1Department of Endocrinology, University of Liverpool, Liverpool, UK
  2. 2Cardiology Department, East Cheshire NHS Trust, Macclesfield, Cheshire, UK
  1. Correspondence to Dr Rebecca Dobson, rebeccadobson{at}doctors.org.uk

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Description

An 82-year-old woman was investigated for weight loss and malaise. Clinical examination revealed cachexia, dyspnoea, irregular pulse, loud pan-systolic murmur best heard at cardiac apex along with a diastolic tumour plop sound.

Figure 1

Trans-thoracic apical four-chamber view.

Figure 2

Trans-oesophageal short-axis view.

Figure 3

Trans-oesophageal image illustrating left ventricular outflow tract obstruction.

The patient underwent transthoracic ECG examination (figures 13). A large mass measuring 36×39 mm was noted in the left atrium. It descended into the left ventricle (LV) during diastole, leading to dynamic inflow obstruction. There was an eccentric jet of moderate mitral regurgitation, directed around the lateral border of the mass. In addition, there was severe tricuspid regurgitation, with an estimated pulmonary pressure 55−60 mm Hg.

A subsequent trans-oesophageal ECG demonstrated a gelatinous, heterogeneous mass with echolucent regions attached to the anterior mitral valve leaflet. The appearance was consistent with atrial myxoma. The mitral valve apparatus appeared intact; there was dynamic LV inflow obstruction, which was considered to be the origin of the ‘plop’ sound.

The patient was referred for urgent surgical resection. The mass and segment of the mitral valve leaflet from which it originated were excised. The anterior mitral leaflet was repaired with a bovine patch. Histological examination confirmed the diagnosis of atrial myxoma.

The commonest site of origin is the interatrial septum, but they can arise from elsewhere in the heart, as demonstrated by our image. The incidence of atrial myxomas is unknown. The surgical incidence in the Republic of Ireland was 0.5 per 1 million population per year.1 Although rare, they are an important differential diagnosis as they have an excellent prognosis if treated in a timely manner.

Learning points

  • Atrial myxomas are often missed—it is important to consider them in the differential diagnosis as they have an excellent prognosis when resected.

  • Timely diagnosis and intervention reduce the risk of complications, including thromboembolic phenomena, pulmonary oedema and obstruction of the mitral valve.

Reference

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Footnotes

  • Competing interests None.

  • Patient consent Obtained.

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