Quiescent left atrial myxoma

Rapid expansion of a left atrial myxoma caused by acute multiple internal hemorrhages: a case report and literature review

BACKGROUND

Left atrial myxoma is the most common benign tumor, with the growth rate remaining unknown because specific symptoms do not present until the tumor grows to a certain size. Early surgical management is performed in most cases once it is detected by physicians. Despite cardiac myxomas commonly being perceived as slow-growing tumors, rapid enlargement of myxomas has been reported.

CASE PRESENTATION

A 64-year-old woman was referred to our hospital with a diagnosis of a left atrial tumor. The pointed tumor changed morphologically in a few hours, and her respiratory condition, which had been normal at admission, suddenly deteriorated. Emergent surgery was performed, and the diagnosis was myxoma with multiple intratumor massive hematomas. The patient recovered uneventfully and was discharged on postoperative day 12 without any complications.

CONCLUSIONS

We report an extremely rare case of left atrial myxoma rapidly expanded due to acute multiple hemorrhages within itself. Massive internal hemorrhage alters the size, shape, and fragility of the tumor. We should recognize the potential risk of internal hemorrhage that may lead to acute deterioration of the so-called "slow-growing benign" tumors, such as myxomas.

30-year follow-up of an unoperated left atrial myxoma: a case report

Background

Cardiac myxomas are the most common benign primary cardiac tumours. The natural history of left cardiac myxomas is thought to be of slowly growing tumours. Cardiac myxomas are a heterogeneous group with a variable growth rate. They present usually with stroke, valve obstruction, or non-specific symptoms. Surgical resection is the effective treatment.

Case summary

This case report describes a 56-year-old hypertensive and dyslipidaemic female, when she was admitted in January 1990, complaining of loss of appetite, aches, pains, and palpitations. Her workup included a transthoracic echocardiography and transoesophageal echocardiography, which showed a left atrial mass attached to the inter-atrial septum, highly suggestive of left atrial myxoma. She was referred for surgical removal of the left atrial mass. However, she was reluctant to undergo surgery as she felt better. The patient was followed-up for almost 30 years with the left atrial mass confirmed as left atrial myxoma by cardiac magnetic resonance imaging. The left atrial mass became smaller in size and more calcified.

Discussion

Cardiac myxomas are a group of heterogeneous tumours, thought to be slowly growing. The growth rate of cardiac myxomas prior to diagnosis is not well known, as the vast majority is treated with surgical resection immediately after diagnosis. Our case showed the natural progression of an unoperated smooth-surfaced left atrial myxoma followed-up for almost 30 years, which slowly became smaller and more calcified.

Right Atrial Myxoma Originating from Tricuspid Septal Leaflet

A unique case of right atrial myxoma originating from the septal leaflet of the tricuspid valve is described. The tumor was detected by echocardiography and resected along with part of the septal leaflet, followed by primary repair.

Left ventricular inflow tract obstruction secondary to a myxoma in a dog

This is the first description of a left ventricular inflow tract obstruction secondary to a myxoma in a dog. A 4 yr old, male fox terrier presented with a 1 mo history of cough and exercise intolerance. Expiratory dyspnea, pulmonary crackles, irregular cardiac rhythm, and a grade 4/6 pansystolic cardiac murmur over the left cardiac apex were the most important features on physical examination. The electrocardiogram revealed atrial fibrillation. Thoracic radiographs showed left-sided cardiac enlargement and mild pulmonary edema, especially in the hilar area. Two-dimensional transthoracic echocardiography showed severe left atrial dilation and a homogenous, echodense mass involving both leaflets of the mitral valve and the posteromedial papillary muscle, inducing mitral stenosis. Spectral Doppler echocardiography was consistent with severe left ventricular inflow tract obstruction secondary to a mass. Therapy for congestive heart failure was prescribed. Follow-up examinations of the dog 1 mo, 2 mo, and 6 mo after diagnosis showed an improvement in clinical signs, but similar echocardiographic features. Eleven months after diagnosis, the dog was euthanized at the owner's request because of recurrent congestive heart failure. The postmortem examination showed the cardiac tumor was consistent with a myxoma.

Atrial myxomas grow faster than we think

The finding of a cardiac myxoma usually implies immediate consequent surgical excision to prevent embolic events. Reports with documented growth rate are therefore very rare, and the actual growth rate remains a controversial issue. We report the growth of a left atrial myxoma in an asymptomatic 65-year-old patient with several years of follow up for aortic valve disease. A MEDLINE search with the terms "cardiac myxoma and tumor growth" was performed. The calculated growth rate showed an average growth rate of 0.49 cm/month. These reports suggest that the growth rate of myxomas may be faster than is usually thought.

Endometrial Adenocarcinoma with Concomitant Left Atrial Myxoma

Background

Atrial myxomas are the most common primary heart tumors and predominantly considered to be benign lesions. Case Study: We report a case involving a 77-year-old woman who presented with a pelvic mass. She was found to have a primary endometrial cancer and primary lung cancer with concomitant metastatic adrenal gland and mesenteric lesions. Her prior medical history also included an untreated 4.0 × 2.0-cm left atrial myxoma which was identified on CT scan during the workup of her pelvic mass.

Results

A clinical decision was made to proceed with surgery for the pelvic mass with a subsequent recommendation for left atrial mass resection. Currently, the patient is scheduled to begin chemotherapy for primary lung cancer.

Conclusion

The reported incidence of uterine cancer and a concurrent atrial myxoma is very rare. Consequently, the manner and timing in which treatment should be provided is imprecise. In the present case, the risk for cardiac complications was high, but given the presence of a partial bowel obstruction and the need to diagnose the primary site of her metastatic malignancy, the decision was made to proceed with exploratory abdominal surgery.

How Fast Does an Atrial Myxoma Grow?

We describe the case of a 58-year-old man who underwent coronary artery bypass grafting with an unremarkable transesophageal echocardiogram. Three years later he underwent a routine transthoracic echocardiogram that was normal. Eleven months later he presented with dyspnea and right-sided heart failure. Transthoracic echocardiogram showed a large mass located in the right atrium in which the base was inserted by the junction of the inferior vena cava and coronary sinus. Pathology showed a myxoma that measured 15 x 3 cm implying a growth rate of 1.36 x 0.3 cm/month.

Atrial myxoma: case report and a review of the literature

Atrial myxomas are the most common benign primary tumor of the heart and occur in as many as 3 in 1000 patients. These tumors are a major cause of patient morbidity and mortality. Although the majority of atrial myxomas occur in the left atrium, 3 separate familial myxoma syndromes can result in multiple myxomas in atypical locations. Approximately 50% of patients with myxomas may experience symptoms due to central or peripheral embolism or intracardiac obstruction, but 10% of patients may be completely asymptomatic. Screening for myxomas should involve a thorough history and physical examination and a transthoracic and/or transesophageal echocardiogram. Transthoracic echocardiography is approximately 95% sensitive for the detection of cardiac myxomas, and transesophageal echocardiography approaches 100% sensitivity. Though the majority of atrial myxomas are sporadic, it is imperative that first-degree relatives of patients with documented myxomas undergo screening for occult myxomas. Surgical removal of the myxoma is the treatment of choice and usually curative; however, myxoma recurrence does occur and is most frequently associated with a familial syndrome.

Long-term survival of quiescent left atrial myxoma in an elderly patient

Left atrial myxoma, if left untreated, is inexorably progressive and usually fatal. The classical management of this disease is prompt surgical removal. However, there may be exceptions to this traditional dogma. The authors report an 85-year-old man who presented with features of chronic obstructive airway disease and congestive heart failure 15 years previously. Auscultation of the heart showed a pansystolic murmur. Two-dimensional echocardiography revealed a nonobstructive, calcified, and well circumscribed mass in the left atrium, with a pedicle attached to the interatrial septum. Because the patient refused high-risk cardiac surgery related to his comorbidity, he was managed medically with a bronchodilator, diuretics, and digoxin. There have been no features of embolism or intracardiac obstruction, and serial echocardiography demonstrates no disease progression over this long period of time. This case illustrates that calcified left atrial myxoma may exhibit a quiescent phase. Tumor calcification, slow growth potential, and the absence of intracardiac obstruction may correlate with a better outcome in the elderly patient.

Twenty-Five Years of Experience with Left Atrial Myxoma

Forty-four patients with left atrial myxoma were operated at Türkiye Yüksek İhtisas Hospital between 1971 and 1996. There were 31 female and 13 male patients. The myxoma arose from the interatrial septum in 43 patients and from the annulus of the posterior leaflet of the mitral valve in one patient. Preoperatively, all patients had dyspnea or tachycardia. Clinical evidence of systemic embolism was detected in 9 patients. The diagnosis was established by angiocardiography in 6 patients and by echocardiography in 38 patients. All patients were treated surgically under cardiopulmonary bypass and the myxomas were resected with their septal attachments. The septal defects were closed with a patch in 12 patients and primarily in 32 patients.

Cardiac myxomas

Although cardiac myxomas are histologically benign, they may be lethal because of their strategic position. They can mimic not only every cardiac disease but also infective, immunologic, and malignant processes. Myxomas must therefore be included in the differential diagnosis of valvular heart disease, cardiac insufficiency, cardiomegaly, bacterial endocarditis, disturbances of ventricular and supraventricular rhythm, syncope, and systemic or pulmonary embolism. The symptoms depend on the size, mobility, and location of the tumor. Echocardiography, including the transesophageal approach, is the most important means of diagnosis; CT and MRI may also be helpful. Coronary arteriography in patients over 40 years of age is generally required to rule out concomitant coronary artery disease. Surgical removal of the tumor should be performed as soon as possible; the long-term prognosis is excellent, and recurrences are rare. In follow-up examinations as well, echocardiography is essential.