Asian Cardiovasc Thorac Ann 1999;7:150-152
© 1999 Asia Publishing EXchange Pte Ltd
Myxomas Causing Coronary Emboli Resulting in Acute Myocardial Infarction
Kutay Ta
demir, MD,
M Halit Andaç, MD,
Hakan Ceyran, MD,
Alptekin Yasim, MD
Department of Thoracic and Cardiovascular Surgery
Erciyes University Medical School
Kayseri, Turkey
|
|
For reprint information contact: Kutay Tademir, MD Tel: 90 352 235 7602 Fax: 96 352 222 3272 Department of Thoracic and Cardiovascular Surgery, Erciyes University Medical School, Kayseri 38038, Turkey.
|
 |
Abstract
|
|---|
A 26-year-old female presented with chest pain, numbness in the legs, and electrocardiographic signs of left ventricular aneurysm and recent myocardial infarction. Transesophageal echocardiography detected a mass in each atria. Angiography demonstrated normal coronary arteries, a left ventricular aneurysm, and an apical thrombus. At surgery, myxomas were excised from both atria and the aneurysm was plicated, followed by peripheral embolectomy. The patient made a good recovery.
|
Introduction
|
|---|
Myxomas are the most common type of primary heart tumor. Generally, they are benign in biologic potential and develop slowly. Although they appear most often in adults over 30 years of age, they can develop at any age and they are three-times more frequent in women than men.1–3 They are often attached to the fossa ovalis in the right atrium and the interatrial septum and are thought to arise from subendothelial cells or primitive endothelial cells, which are found to a great extent in the fossa ovalis.4 We describe a case of biatrial myxomas presenting as coronary embolism in a young female.
|
Case Report
|
|---|
A 26-year-old female presented with chest pain, palpitation, coldness, and numbness in her lower extremities, which had developed suddenly one month previously. She had not seen a doctor during this period and came to our department because the pain had increased. Her arterial blood pressure was 110/90 mm Hg, heart rate 125 beats•min–1, and body temperature 36.5°C. On auscultation, crepitant rales were heard on the right side. The left upper extremity was normal but no pulsations were felt in the right upper extremity. An electrocardiogram showed sinus tachycardia, a left ventricular aneurysm, and recent anterior myocardial infarction. Biochemical findings were as follows: lactate dehydrogenase 2645 U•L–1, creatine kinase 316 U•L–1, and creatine kinase-MB isoenzyme 220 U•L–1. Transesophageal echocardiography revealed two separate moving masses, one in each atria (Figure 1
). The mass in the right atrium was located below the atrial septum and moved towards the tricuspid valve. Movement of the septum was suppressed, the left chambers were vastly distended, and there was mild tricuspid insufficiency. These findings were attributed to biatrial myxomas and in view of the electrocardiogram and enzyme studies, it was thought that the patient had suffered acute myocardial infarction due to thromboembolism. Therefore, emergency coronary angiography was performed. This showed that the coronary arteries were normal and there was an aneurysm in the left ventricle resulting from myocardial infarction and apical thrombus (Figure 2). The clarity of the coronary arteries in spite of the aneurysm was considered to be due to recanalization.
The patient underwent emergency surgery within 4 hours of these findings because of the risk of further em-bolization. A median sternotomy was performed under neuroleptic anesthesia. Cardiopulmonary bypass was established with moderate hypothermia after selective venous and ascending aortic cannulation. Cardiac arrest was achieved with aortic cross-clamping and cold crystalloid potassium cardioplegia. After opening the right atrium, the mass was excised (Figure 3), the other mass in the left atrium was excised transseptally, and the aneurysm in the left ventricle was plicated (Figure 4). After decannulation, embolectomy was performed on both lower extremities and the patient was taken to the intensive care unit where she required an infusion of dopamine (7 µg•kg–1•min–1) to treat low cardiac output syndrome. The rest of the postoperative course was uneventful and after 26 months of follow-up, the patient is well and symptom-free.
|
Discussion
|
|---|
The most frequent symptoms of myxoma are dyspnea, fever, pericardial pain, and syncope. If not excised, these tumors may be fatal due to valvular obstruction or major embolic problems. Emboli occur in approximately 64% of patients with left atrial myxoma. In our patient, all of these symptoms were present along with emboli in the lower extremities and an aneurysm in the left ventricular apex as a result of coronary embolism. Three cases of cardiac myxoma causing myocardial infarction have been reported.5 Echocardiography is usually sufficient for the diagnosis of myxoma but coronary angiography was also performed in this patient because of the electrocardio-graphic and enzyme changes. There is disagreement as to whether two-dimensional transthoracic or transesophageal echocardiography is superior for diagnosing masses in the heart.2,6,7 In our patient, the moving masses in each atria were diagnosed by both methods.
A patient with biatrial masses must be examined for systemic and pulmonary emboli. Surgical resection of myxomas is mandatory.8 During surgery, manipulation of the heart must be minimized, the attachment point must be determined without mobilizing the tumor, and the tumor must be completely excised.8 We chose the right atrial approach in this patient because the right atrial mass was mobile; the left atrial mass was excised transseptally. Mitral or tricuspid insufficiency may be present to various degrees in some cases.8 This can be due to stress on the annulus and chord from tumor prolapse, as was found in our patient. In addition to stressing the need for total and urgent excision of cardiac myxomas, this case is reported to highlight the importance of considering a diagnosis of myxoma when there is myocardial infarction associated with peripheral embolism.
|
References
|
|---|
-
Chitwood WR Jr. Clarence Crafoord and the first successful resection of a cardiac myxoma. Ann Thorac Surg 1992;54:997–8.[Abstract]
-
Samdarshi TE, Mahan EF, Nanda NC, Guthrie FW, Bernstein IJ, Kirklin JW. Transesophageal echo-cardiographic diagnosis of multicentric left ventricular myxoma mimicking a left atrial tumor. J Thorac Cardiovasc Surg 1992;103:471–4.[Abstract]
-
Ergina PL, Kochamba GS, Tchervenkov CI, Gibbons JE. Atrial myxomas in young children: an alternative surgical approach. Ann Thorac Surg 1993;56:1180–3.[Abstract]
-
Jones DR, Hill RC, Abbott AE Jr, Gustafson RA, Murray GF. Unusual location of an atrial myxoma complicated by a secundum atrial septal defect. Ann Thorac Surg 1993;55:1252–3.[Abstract]
-
Isobe N, Kanda T, Sakamato H, Morishita Y, Suzuki T, Kobayashi I. Myocardial infarction in myxoma patients with normal coronary arteries. Case report. Angiology 1996;47:919–23.
-
Farah MG. Familial cardiac myxoma. A study of relatives of patients with myxoma. Chest 1994;105:65–8.[Abstract/Free Full Text]
-
Kaplan LJ, Weiman DS, VanDecker W, Sokil AB, Whitman GJR. Infected biatrial myxoma: transesophageal echo-cardiography – guided surgical resection. Ann Thorac Surg 1994;57:487–9.[Abstract]
-
Kabbani SS, Jokhadar M, Meada R, Jamil H, Abdun F, Sandouk A, et al. Atrial myxoma: report of 24 operations using the biatrial approach. Ann Thorac Surg 1994;58:483–8.[Abstract]
TOP
Abstract
Introduction
