Risk factors for embolism in cardiac myxoma: a retrospective analysis

Complex decision making in a patient with lung cancer with incidentally found fast-growing atrial mass

Atrial myxomas are typically found in the left atrium and are the most common among overall rare cardiac tumors. Herein, we describe the clinical course of a 72-year-old female with non-small cell lung adenocarcinoma found to have an atrial mass during an imaging for evaluation for lung cancer progression. Differentiating between distinct types of masses can pose a challenge to the treatment team especially in the setting of exiting malignancy. This case demonstrates the complex decision making involved in the diagnosis, and timing of intervention to remove atrial mass in patients with frailty and a fast-growing cardiac mass.

Giant left atrial myxoma causing acute ischemic stroke

Atrial myxomas are primary cardiac tumors which may cause ischemic stroke. The authors present a case of a 51-year-old man admitted to the emergency department with right-sided hemiplegia and aphasia caused by ischemic stroke. 2D and 3D transesophageal echocardiography showed an atrial myxoma described as a large mass in the left atrium attached to the interatrial septum. In the end, surgical excision of the myxoma was performed 48 h after diagnosis. Nowadays, specific guidelines concerning the correct time for surgical excision of the myxoma are lacking. The authors highlight the utmost role of echocardiography to promptly characterize a cardiac mass and the importance of discuss about the timing of cardiac surgery.

Rare renal embolic manifestation of left atrial myxoma: A case report

INTRODUCTION AND IMPORTANCE

A complete occlusion of the renal artery due to atrial myxoma is a rare occurrence.

CASE PRESENTATION

Here we present a case of a completely occluded left renal artery caused by atrial myxoma emboli that presented with a 14-hour history of sudden onset sharp left flank pain radiating to the left lower quadrant of the abdomen, nausea, with preserved kidney function. Revascularization is unlikely to benefit the patient because it has been more than 6 h since the onset of ischemia. Anticoagulation therapy was initiated, followed by myxoma resection. The patient was discharged with no evidence of nephropathy.

CLINICAL DISCUSSION

Anticoagulation with or without thrombolysis is the standard treatment strategy for renal artery embolism. Given the delayed presentation of renal artery occlusion and the nature of the embolism, revisualization is not beneficial for this case.

CONCLUSION

Emboli of atrial myxoma caused renal artery occlusion is rare. Thrombolysis or surgical revascularization can be used to restore perfusion for renal artery embolism. However, the likelihood of benefit from revascularization must be assessed.

Clinical characteristics of primary atrial tumor and their diagnostic value: A retrospective study of 10 years

Background

Primary atrial tumors are relatively rare and predominantly benign. However, some atrial tumors may be malignant and are associated with poor outcome. Currently, it is hard to determine the malignance of atrial tumors by preoperative clinical presentation or by echocardiography. We aimed to report the difference in the clinical characteristics of patients with benign and malignant atrial tumor.

Methods

This was a single-center retrospective study. A total of 194 patients with primary atrial tumor admitted to our center between 2012 and 2021 were included. The clinical characteristics of patients with benign and malignant tumor were compared.

Results

Benign and malignant tumor accounted for 93% (n = 180) and 7% (n = 14) of the total patients, respectively. Malignant atrial tumor tended to occur in younger patients (P < 0.05), was more likely to be located at the right atrium (P < 0.05), and tended to attach to the atrial wall or valve instead of the atrial septum. Fever symptoms were more common in patients with malignant tumors than in patients with benign tumors (P < 0.05). Compared to benign tumor, patients with malignant atrial tumor also demonstrated higher rates of fever, lower rates of increasing fibrinogen, increased blood glucose (P < 0.05), significantly longer prothrombin time, and lower prothrombin activity (P < 0.05). Patients with malignant primary atrial tumor had higher mortality rate, tumor metastasis rate, and tumor recurrence rate than patients with benign primary atrial tumor (P < 0.05).

Conclusion

We compared the clinical characteristics of patients with benign and malignant atrial tumor. These findings provide valuable information to preoperatively determine the malignance of atrial tumor and thus guide surgical treatment.

Morphological characteristics of cardiac myxoma causing embolism: a series of 40 years of experience at a single institute

Systemic and cerebral embolisms are serious complications of associated with cardiac myxoma. Embolism risk reportedly depends on the gross and histological morphology. This study is aimed at analyzing the morphologic pattern of excised cardiac myxoma as a high-risk embolic cause. Between 1978 and April 2022, 116 surgical specimens of cardiac myxomas were recorded at the pathology department of our hospital. The tumors were classified into three types based on their macroscopic shapes and external morphology-round-smooth, irregular, and villous-to investigate the embolic complications. Of the 116 specimens, 106 macroscopic images of cardiac myxoma (89% were located in the left atrium) were prepared. Round-smooth types were found in 36 (34.0%) patients, irregular types in 32 (30.2%) patients, and the villous types in 38 (35.8%) patients. Multivariable analysis revealed that a villous external appearance was an independent predictor of embolic events (odds ratio: 8.7; 95% confidence interval: 2.4-42.1; p < 0.001). Villous external appearance of cardiac myxoma was associated with the highest risk of distal embolism.

Clinical features, risk factors and survival in cardiac myxoma-related ischemic stroke: A multicenter case-control study

BACKGROUND

Cardiac myxoma (CM) is an important etiology of stroke in young adults, but studies on CM-related ischemic stroke (CM-IS) are limited and conflicting. Hence, we investigated clinical characterizations, risk factors of CM-IS, and short-term survival after surgical resection.

METHODS

We performed a retrospective analysis of data from all CM patients at three referral management centers and conducted follow-up examination.

RESULTS

Among 414 CM patients, 402 were recruited for further analysis, including 54 patients with CM-IS and 348 patients with CM without stroke (Non-stroke). In the acute phase, patients presented with NIHSS 3 (interquartile range: 0-10) and clinical presentation comprising neurological, cardiac and constitutional symptoms. Multivariate analysis showed that the factors associated with an increased risk of CM-IS were tumor width < 30 mm [OR = 2.652, 95% CI: 1.061-6.627, P = 0.037], tumors with high-mobility (OR = 2.700, 95% CI: 1.357-5.371, P = 0.005), thrombus on the tumor surface (OR = 1.856, 95% CI: 1.003-3.434, P = 0.049), and lower B-type natriuretic peptide (BNP) levels (OR = 0.995, 95% CI: 0.989-0.999, P = 0.047). The overall three-year survival rate was 95.7% (95% CI: 94.9-96.5) in CM-IS patients who underwent surgery.

CONCLUSIONS

CM-IS patients had mild or moderate neurologic deficits with various presentations at disease onset. Narrower tumor width, tumors with high-mobility, thrombus on the tumor surface, and lower BNP levels are potential predictors of CM-IS development. Surgical removal of CM is safe and efficacious in patients with CM-IS.

Risk factors assessment and a Bayesian network model for predicting ischemic stroke in patients with cardiac myxoma

Objective

This study aims to identify relevant risk factors, assess the interactions between variables, and establish a predictive model for ischemic stroke (IS) in patients with cardiac myxoma (CM) using the Bayesian network (BN) approach.

Methods

Data of patients with CM were collected from three tertiary comprehensive hospitals in Beijing from January 2002 to January 2022. Age, sex, medical history, and information related to CM were extracted from the electronic medical record system. The BN model was constructed using the tabu search algorithm, and the conditional probability of each node was calculated using the maximum likelihood estimation method. The probability of each node of the network and the interrelationship between IS and its related factors were qualitatively and quantitatively analyzed. A receiver operating characteristic (ROC) curve was also plotted. Sensitivity, specificity, and area under the curve (AUC) values were calculated and compared between the BN and logistic regression models to evaluate the efficiency of the predictive model.

Results

A total of 416 patients with CM were enrolled in this study, including 61 with and 355 without IS. The BN model found that cardiac symptoms, systemic embolic symptoms, platelet counts, and tumor with high mobility were directly associated with the occurrence of IS in patients with CM. The BN model for predicting CM-IS achieved higher scores on AUC {0.706 [95% confidence interval (CI), 0.639-0.773]} vs. [0.697 (95% CI, 0.629-0.766)] and sensitivity (99.44% vs. 98.87%), but lower scores on accuracies (85.82% vs. 86.06%) and specificity (6.56% vs. 11.48%) than the logistic regression model.

Conclusion

Cardiac symptoms, systemic embolic symptoms, platelet counts, and tumor with high mobility are candidate predictors of IS in patients with CM. The BN model was superior or at least non-inferior to the traditional logistic regression model, and hence is potentially useful for early IS detection, diagnosis, and prevention in clinical practice.

Ischemic Stroke in Patients With Malignancy

Approximately one-quarter to one-third of patients with ischemic stroke have an embolic stroke of undetermined source (ESUS). An estimated 5% to 10% of patients with ESUS have an active cancer diagnosis. Presence of cancer potentially increases the risk of acute ischemic stroke through various mechanisms such as cancer-related hypercoagulability, intracranial tumors leading to an arterial compression, or intracardiac tumors leading to cardioembolism. Certain cancer therapeutics can also contribute to risk of ischemic stroke. Multiple vascular lesions involving bilateral anterior and posterior circulations, high plasma D-dimer levels, and elevated inflammatory markers might suggest cancer-related ischemic stroke. Patients with ischemic stroke related to malignancy are also at higher risk of stroke recurrence, early neurologic deterioration, and mortality. Cancer screening in acute ischemic stroke patients can be considered when no other etiology for stroke can be established and clinical history such as tobacco use, unexplained constitutional symptoms such as fever or night sweats, or unexplained weight loss suggests an underlying malignancy. Selection of antithrombotics for secondary stroke prevention remains controversial as clinical trial data for use of antiplatelet therapy vs anticoagulation in ESUS and cancer patients is limited. Future clinical trials should specifically focus on patients with ischemic stroke related to malignancy are needed to guide appropriate therapeutic agent selection.

Post-Acute COVID-19 syndrome (PACS) right atrioventricular and vena cava thrombus on top of a myxoma. A Case report

Post-Acute COVID-19 syndrome (PACS) is considered to be one of the least understood post-infectious syndromes. We report a case of a 21-year-old female who had a history of SARS-CoV-2 infection and presented with a right atrioventricular thrombus associated with pulmonary embolism and thrombocytopenia. At the time of admission, she was not vaccinated against SARS-CoV-2, and her serological tests for IgG and IgM antibodies against SARS-CoV-2 were positive. The size of the thrombus measured approximately 6 × 8 × 4 cm, which also led to tricuspid valve insufficiency due to mechanical dilatation of the valve’s ring. The right atrioventricular thrombus also extended up to the inferior vena cava, leading to mild congestive hepatomegaly. Moreover, during thrombectomy, the mass of the thrombus was attached to the interseptal right atrial wall. The histopathological assessment of the core mass revealed that it was a right atrial myxoma hidden inside that large thrombus. We suspect that the formation and propagation of the thrombus to that size occurs as a part of Post-Acute COVID-19 syndrome (PACS). This study reviews and discusses coronavirus disease 2019-relate to thrombus formation inside cardiac chambers in case of a cardiac tumor, like myxoma in the setting of post-acute phase COVID-19 syndrome.

Atrial Myxoma Presenting as an Atypical Stroke in a Young Patient With a Recent COVID-19 Infection

Atrial myxomas are the most common primary tumor of the heart and can occasionally present as an ischemic stroke with neurologic symptoms secondary to embolic phenomena. We present a case of a 42-year-old male with multiple cardiovascular risk factors and coronavirus disease 2019 (COVID-19) infection two months prior who presented to the emergency department with unilateral left-sided weakness and paresthesia. After being diagnosed with multifocal ischemic strokes, further evaluation utilizing a transesophageal echocardiogram (TEE) revealed a 5 × 2 cm left atrial myxoma prolapsing the mitral valve, which was the presumed cause of the patient’s strokes. The myxoma was successfully removed via robotic thoracoscopy. Our case demonstrates the importance of considering atrial myxoma in the evaluation of stroke in young and middle-aged patients even in the presence of multiple cardiovascular and thrombotic risk factors.

Cardiac myxomas: A narrative review

Cardiac myxomas are common primary neoplasms of the heart. They are biologically benign but “functionally malignant” because of the potential for embolization. They arise most commonly from the left atrium, but no chambers of the heart are immune. They may be sporadic in the majority but also familial as a part of the Carney complex. Two morphological forms exist: polypoid and papillary. Polypoid myxomas often present with obstructive features, while the papillary forms are more prone to embolization. Histogenesis is still controversial; the current view centres around origin from the primitive pluripotent mesenchymal cells. They may be of giant proportion, be calcified or get infected. Clinical presentation typically involves the triad of intracardiac obstruction, embolic events and constitutional symptoms. Precordial examination findings may simulate those of mitral or tricuspid stenosis. The presence of tumour plop and change of the physical findings with changing position may help differentiation between the two. Echocardiography is the investigation of choice. Echogenic polypoid or papillary mobile mass within the atrial cavity remaining attached to the interatrial septum through a stalk are the tell-tale echocardiographic features. Cardiac magnetic resonance and computed tomographic scanning may have incremental diagnostic value. Histopathological examination reveals abundant loose myxoid stroma with scattered round, polygonal or stellate cells with dense irregular nuclei. Genetic testing may detect mutations in the PRKAR1A gene in the familial form of cardiac myxoma, i.e. the Carney complex. Surgical excision is the mainstay of treatment with low operative mortality, excellent postoperative survival and low recurrence rate. The current trend favours minimal-access surgery with or without robotic assistance. Physicians should have appropriate preparedness to make a timely diagnosis and enthusiastic treatment to avoid potentially fatal complications.

Chronic migraine with aura as a neurologic manifestation of an atrial myxoma - A case report

Introduction and importance

Case presentation

Clinical discussion

Conclusion

Predictors of Late Mortality in Patients With Surgically Resected Cardiac Myxomas: A Single-Center Experience

Background and objective

Myxomas are the most common cardiac tumors. This study aimed to analyze the possible risk factors associated with late mortality in this group of patients and assess long-term survival.

Methods

A retrospective study was conducted among patients who underwent myxomas resection between January 2008 and July 2019 in our service. The patients' preoperative, intraoperative, and postoperative data were analyzed. Multivariate logistic regression was performed to identify predictors of mortality at five years. The Kaplan-Meier curve and Cox proportion-adjusted survival curves were used to assess mortality at five and 10 years.

Results

A total of 108 patients with cardiac myxomas were identified. All cardiac tumors resected were confirmed as myxomas on histopathological examination. Ninety-six patients presented with left-side myxomas (94 left-atria and two left-ventricle) and 12 with right-side myxomas (11 right-atria, one right-ventricle); 78 of the tumors were capsulated, and 30 were sessile-papillary. The mean dimensions were 37 ±6.1 mm on the left side and 41 ±6.7 mm on the right side. Surgical excision was successful in all cases, with 25% requiring interatrial septum patch repair. Recurrence occurred in 2.77% of the patients. Multivariate logistic regression showed chronic kidney disease (CKD) (OR: 7.96, 95% CI: 1.469-43.125, p=0,016) to be an independent predictor for five-year mortality. The mean follow-up period was 7.13 ±2.965 years, and the Kaplan-Meier curve cumulative proportion survival of patients at five years and 10 years were 100% and 88.8%, respectively. There was no statistically significant difference in late-term survival between patients with and without CKD in the Cox proportion-adjusted survival curve (p=0.275).

Conclusions

Patients with myxomas have a good long-term prognosis following surgical resection. The multivariate logistic regression showed CKD to be an independent predictor of five-year mortality.

Clinical Significance of Angiographically Detectable Neovascularity in Patients with Cardiac Myxoma

Background: Myxomas are the most common primary cardiac tumors. Angiographically detectable neovascularity (ADN) of myxoma is increasingly being reported as a result of the use of coronary angiography (CAG) to detect coronary artery disease. However, the clinical significance of these findings is not fully understood.Methods: We enrolled 59 patients with cardiac myxoma who also underwent CAG between January 2013 and October 2018. Patients were followed up for a mean of 28.9 months (range 1‐69 months). The clinical features, echocardiography measurements, pathological examination findings, CAG results, and outcomes during follow-up were compared between patients with ADN and patients without ADN.Results: ADN was found in 25 patients (42.4%). The arteries feeding the ADN included the right coronary artery (n=15), the left circumflex coronary artery (n=7), and both arteries (n=3). The patients with ADN had a higher proportion of eosinophils (3.2% vs. 2.2%, P=0.03) and higher low-density lipoprotein cholesterol level (2.7 mmol/L vs. 2.2 mmol/L, P=0.02). Myxoma pedicles were more likely to be located in the interatrial septum in patients with ADN (96% vs. 73.5%, P=0.02). No significant correlation was observed between the groups in clinical manifestations, atrial arrhythmia, myxoma size, cardiac chamber size, left ventricular ejection fraction, and the prevalence of complication with coronary artery disease [16% in the ADN group (n=4) vs. 20.6% in the non-ADN group (n=7), P=0.66]. However, patients with ADN tended to have a lower incidence of major adverse cardiac and cerebrovascular events on long-term follow-up (0% vs. 14.7%, P=0.07).Conclusion: CAG-detected ADN in patients with cardiac myxoma is associated with a borderline lower rate of major adverse cardiac and cerebrovascular events.

Unusual Presentation of Atrial Myxoma: A Case Report and Review of the Literature

BACKGROUND Although rare, atrial myxoma is the most common benign cardiac tumor. The recognized triad of presenting symptoms relates to constitutional, embolic, and obstructive effects produced by the tumor. However, the presentation may be non-specific and mimic other diseases, confounding diagnosis. CASE REPORT A middle-aged woman presented with wheezing and shortness of breath. With a strong background smoking history, the initial impression was that of acute bronchospasm. She however deteriorated rapidly, with decreased consciousness and cardiac arrest requiring resuscitation. Despite intensive care management, she died within 1 day of admission. Autopsy revealed a previously undiagnosed left atrial myxoma with coronary and systemic embolization. CONCLUSIONS This case highlights an unusual presentation of atrial myxoma, resulting in fatal simultaneous embolization to the coronary and cerebral arteries. This simultaneous embolic presentation is not common, but the potential consequences are serious. This report also demonstrates that the presentation of a left-sided atrial myxoma with cardiac asthma can mimic respiratory disease and confound diagnosis. In adult patients without a history of chronic respiratory disease, the possibility of cardiac asthma should always be entertained. Furthermore, the importance of considering atrial myxoma as a cause for cardiac asthma is emphasized. The use of transthoracic echocardiogram in aiding the rapid diagnosis of atrial myxoma is recommended. Finally, the continued acknowledgement of the important contribution the academic autopsy makes in complementing and improving clinical practice remains imperative.

Cerebrovascular manifestations of tumors of the heart

Primary tumors of the heart, most commonly myxoma, are an uncommon cause of ischemic stroke and intracranial aneurysms. The tumors may occur in any age group but are most frequently detected in middle-aged persons with an atypical or cryptogenic stroke. While some patients will have a history of cardiac or constitutional symptoms, in many cases ischemic stroke will be the initial manifestation of the cardiac mass. Myxomas are the most common cardiac tumors, and valvular fibroelastoma is also a potential cardiac cause of stroke. Among patients with stroke, the most common location for a myxoma is the left atrium. Elevations of inflammatory markers provide clue for a myxoma. Cardiac imaging is the most definitive diagnostic study. Treatment centers on surgical removal of the cardiac mass may be curative.

Characterizations of Ischemic Stroke Complications in Cardiac Myxoma Patients at a Single Institution in Eastern China

BACKGROUND

Cardiac myxoma is the most common primary cardiac tumor. Even though it rarely causes a stroke, it is an important risk factor. Here, we compared our clinical experience in managing myxoma patients who developed stroke complications with those who did not present with this condition at the First Affiliated Hospital of Wenzhou Medical University.

PATIENTS AND METHODS

The medical records were reviewed of 160 cardiac myxoma patients who were treated in our facility from January 2006 to December 2019. They were separated into either a stroke group or non-stroke group.

RESULTS

Cardiac obstructive symptoms, embolic events and constitutional symptoms were observed in 92 (57.7%), 25 (15.6%) and 18 (11.2%) patients, respectively. Among 23 cardiac myxoma ischemic stroke patients, hypoesthesia (60.9%), hemiparesis (56.5%) and facial paresis (47.8%) were the three most common neurological symptoms. The middle cerebral artery (82.6%) was the most commonly affected vessel, whereas 73.9% of the ischemic patients had multiple stroke lesions. Binary logistic regression analysis showed that coronary heart disease and tumor sizes were independently associated in the stroke group (p <0.05). The 10 years cumulative survival rate was 87.9% for all patients after surgical intervention. There was no significant difference in the 10 years cumulative survival rate between the two groups (80.0% vs 88.9%, p =0.274 > 0.05).

CONCLUSION

The three most common neurological symptoms (hypoesthesia, hemiparesis and facial paresis), the middle cerebral artery and multiple lesions involvements were the definitive markers of patients afflicted with cardiac myxoma stroke. Small tumor sizes were independently associated with these patients. Surgical resection is a relatively safe procedure for treating both the stroke and non-stroke patients.

A review of diagnosis, etiology, assessment, and management of patients with myocardial infarction in the absence of obstructive coronary artery disease

Myocardial infarction (MI) in the absence of obstructive coronary artery disease (MINOCA) is prevalent in around 5% of acute myocardial infarction (AMI) presentations. MINOCA is a heterogeneous entity with many different etiologies. It is important for health care providers to familiarize themselves with the disease process, presentation, and possible underlying causes in order to guide appropriate management strategies. In this article, the authors review the contemporary definition, etiologies and assessment, and management for AMI patients with MINOCA.

Sporadic Form of Recurrent Atrial Myxoma: The Blob Strikes Back

Cardiac myxoma is a benign neoplasm composed of stellate to plump, cytologically bland mesenchymal cells set in a myxoid stroma. Although benign, as they can lead to severe complications, they are often removed surgically. A 39-year-old female presented with a chief complaint of generalized fatigue. Patient had a history of a large 7cm x 2.5cm left atrial myxoma resected at the age of 32 years after she presented with symptoms of dyspnea on exertion. The dyspnea was due to prolapse of the mass through the mitral valve during diastole, leading to functional severe mitral stenosis. The mass was resected with clear margins confirmed on biopsy. On physical examination, heart rate was regular with no murmurs. No signs of congestive heart failure were noted. A 2D echo revealed a mobile structure in the left atrium along with mild mitral regurgitation. Cardiac MRI showed a 21mm x 9mm well defined, pedunculated, mobile mass in the left atrium arising from inter-atrial septum. The mass was hyperintense on T2 weighted images with patchy delayed hyper-enhancement consistent with recurrence of a myxoma. The patient underwent a repeat median sternotomy with the removal of left atrial mass and repair of atrial septum with hemashield patch. The mass was sent for pathological evaluation confirming the diagnosis of recurrent myxoma. On genetic testing, patient tested negative for mutations in PRKAR1A gene (mutated in up to 60%-80% cases with Carney complex), MEN1, RET and sarcoma (TP53) genes. Cardiac myxomas are rare primary benign tumors of the heart with a small recurrence rate. Follow-up studies have rarely reported recurrences after complete resection. However, in our case not only did the patient have the sporadic form of myxoma with recurrence, but it also occurred within three years of the previous resection despite complete removal with clear margins.

Risk factors of embolism for the cardiac myxoma patients: a systematic review and metanalysis

Background

The risk factors contributing to embolism in cardiac myxoma (CM) are yet controversial. This systematic review and meta-analysis aimed to clarify the risk factors of embolism for the CM patients.

Methods

PubMed, Embase, Cochrane library, Web of Science, China National Knowledge Infrastructure, Wan Fang, and Wei Pu databases were searched from inception to June 2019. Statistical analysis was conducted using Stata version 14.0. The pooled odds ratio or mean difference with 95% confidence interval was estimated for each risk factor.

Results

Herein, 12 studies, encompassing 1814 patients, were included. The pooled results suggested that New York Heart Association (NYHA) class I/II (P < 0.01), hypertension (P = 0.03), irregular tumor surface (P < 0.01), tumor in atypical location (P = 0.01), narrow base of tumor (P < 0.01), and increased fibrinogen (FIB) (P < 0.01) are significant risk factors of embolism in CM patients. However, sex, age, body mass index, smoking, left ventricular ejection fraction, diabetes, hyperlipidemia, atrial fibrillation, valvular heart disease, coronary heart disease, tumor size, platelet count, white blood cells, and hemoglobin were not associated with embolism (all P > 0.05).

Conclusions

NYHA class (I/II), hypertension, irregular tumor surface, atypical tumor location, the narrow base of tumor, and increased FIB were significant risk factors of embolism in CM patients. For CM patients with these factors, early surgery might be beneficial to prevent embolism.

Sudden death by massive systemic embolism from cardiac myxoma. Role of the clinical autopsy and review of literature

Cardiac myxoma is a rare benign neoplasm of the heart. Historically myxomas were incidental findings during autopsies, however improved imaging techniques made these diagnosis possible in living patients, making the surgical treatment of these neoplasms achievable. Cardiac myxomas may occur both sporadically and in a familial context, often in the clinico-pathological picture of the Carney complex. While familial myxomas occur in the context of well-known genetic mutations, the molecular etiology of sporadically occurring myxomas is still not completely clear. We must note however that many of the patients affected by myxomas are asymptomatic; when symptoms are present they are often nonspecific and hard to decipher, especially when referring to sporadically occurring heart myxomas. In this paper we describe a case of sudden death from the massive embolization of a left atrial cardiac myxoma. We also reviewed all the cases in the literature of sudden death from heart myxoma embolism. An accurate epidemiology of heart myxomas would be the key to outline the best treatment practices and the etiology of sporadic myxomas, nevertheless this target could only be pursued with a deep revaluation of the clinical autopsy as a fundamental diagnostic tool.

MI with Non-obstructive Coronary Artery Presenting with STEMI: A Review of Incidence, Aetiology, Assessment and Treatment

MI with non-obstructive coronary artery (MINOCA) is a condition previously thought to be benign that has recently been shown to have comparable mortality to that of acute coronary syndrome with obstructive coronary disease. The heterogeneity of the underlying aetiology makes the assessment, investigation and treatment of patients with MINOCA challenging. The majority of patients with MINOCA presenting with ST-segment elevation MI generally have an underlying coronary or myocardial cause, predominantly plaque disruption or myocarditis. In order to make the correct diagnosis, in addition to the cause of the presentation, a meticulous and methodical approach is required, with targeted investigations. Stratification of patients to guide investigations that are more likely to provide the diagnosis will allow the correct treatment to be initiated promptly. In this article, the authors review the contemporary incidence, aetiology, recommended assessment and treatment of patients with MINOCA presenting with ST-segment elevation MI.

A case report of atrial myxoma presenting with systemic embolization and myocardial infarction

Background

Cardiac myxomas are the most common benign primary tumour of the heart. Clinical presentation is variable and ranges from constitutional symptoms to clinical features due to intracardiac obstruction, such as mitral stenosis, coronary embolization, or systemic embolization. Surgical resection is the only effective treatment to prevent its debilitating and catastrophic complication.

Case summary

A 61-year-old woman presented with an-hour history of bilateral leg pain, numbness, lightheadedness, dyspnoea, and diaphoresis. Physical exam was remarkable for pale and cold lower extremities. Arterial pulse was not palpable in the right femoral, popliteal, and posterior tibial and dorsalis pedis arteries bilaterally. Electrocardiogram demonstrated normal sinus rhythm with T-wave inversion in lead I, V2, V3, and V4. Laboratory investigations were remarkable for leucocytosis and elevated troponin. Computed tomography angiogram showed emboli with acute infarcts involving the spleen and kidneys, acute embolic occlusion of right external and internal iliac arteries, and left distal common femoral artery. She underwent emergent bilateral cut-down and femoral artery thrombectomies. Transthoracic echocardiogram demonstrated wall motion abnormalities. Computed tomography angiography of the chest revealed an atrial mass and transoesophageal echocardiography was obtained which confirmed an atrial myxoma. Coronary angiography demonstrated no significant coronary artery disease, raising the possibility of myxoma embolization to the coronary arteries as the cause of her troponin elevation and wall motion abnormality. Subsequently she underwent successful resection of the atrial myxoma.

Discussion

The majority of cardiac myxomas are sporadic and arise from the left atrium as an isolated lesion in middle-aged women. Echocardiography is the diagnostic procedure of choice. The long-term survival after surgical resection is excellent and recurrence is rare.

Atrial Myxoma Presenting as Positional Vertigo: A Case Report

Cardiac myxoma is an uncommon diagnosis but presents with common manifestations. There is a wide range of symptomatology from non-specific fever and weight loss to stroke-like symptoms. It is also one of the rare causes of cardiac syncope and thromboembolic events. We present a case of a 67-year-old female who presented with seemingly benign vertigo symptoms which she ignored for years before seeking medical attention. An echocardiogram revealed a 3.5 x 3.0 x 1.0 cm atrial myxoma which was surgically excised. Her symptoms have resolved entirely with no recurrence since surgery.

Right atrial myxoma presenting as a pulmonary embolism in a 32-year-old female

Primary cardiac tumors are typically benign, with myxomas being most common. We present a 32-year-old female with a chief complaint of dyspnea and a constant non-radiating chest pressure along the left sternal border. She was found to have a pulmonary embolism that was ultimately caused by embolization of a right atrial myxoma with remnants of a large, highly mobile mass attached to the right inter-atrial septum prolapsing through the tricuspid valve. The patient underwent a median sternotomy, right atrial mass resection, pulmonary embolectomy, and inter-atrial septum reconstruction using the patient’s pericardium. The importance of finding the etiology of initial diagnoses is stressed with long-term outcomes for patients.

Long-term outcome of patients with atrial myxoma after surgical intervention: analysis of 403 cases

OBJECTIVE

To assess long-term survival and late cardiovascular events in patients with atrial myxoma after surgical intervention.

METHODS

Retrospective analysis of 403 patients undergoing resection of atrial myxoma from January 2002 to December 2016 was conducted with a median follow-up period of 4.5 (range: 0.5-15) years.

RESULTS

The cross-clamp time and cardiopulmonary bypass times were 41.1 ± 21.4 and 65.2 ± 27.3 min, respectively. A diagnosis of myxoma was histopathologically confirmed in all cases. The early in-hospital mortality rate was 0.7% (n = 3). During the follow-up period, tumor recurrence occurred in six patients and cerebral infarction in nine. There were 48 (11.9%) patients with late onset atrial fibrillation (AF). By multivariate analysis, age (HR = 1.05, 95% CI: 1.02-1.09, P < 0.001), left atrial diameter (HR = 1.23, 95% CI: 1.08-1.36, P = 0.012), and mitral valve surgery (HR = 1.17, 95% CI: 1.05-1.29, P = 0.027) were independent predictors of late onset AF. Twenty-one (5.2%) patients died during the follow-up period. Advanced age (HR = 1.07, 95% CI: 1.04-1.10, P = 0.003) and multiple surgical procedures (HR = 1.18, 95% CI: 1.06-1.29, P = 0.012) were significantly associated with overall mortality.

CONCLUSIONS

Atrial myxoma can be resected with good long-term survival. Late onset AF is common after surgery in patients with atrial myxoma. Advanced age, left atrial diameter, and mitral valve surgery were independent predictors of outcomes.

Neurological manifestations of atrial myxoma: A retrospective analysis

Atrial myxoma is the most common type of primary cardiac tumor and it is closely associated with stroke in adults. Early diagnosis and treatment of atrial myxomas is essential for the prevention of embolic events. The aim of the present study was to assess neurological complications associated with atrial myxoma. The neurological signs of atrial myxoma were retrospectively assessed in individuals who underwent treatment at West China Hospital (Chengdu, China) and The Affiliated Hospital of Hainan Medical University (Haikou, China), between March 2003 and February 2015. A total of 130 patients with atrial myxoma were included and 22 (17%) exhibited neurologic signs. These patients were aged 39.9±12.6 years (range, 13-78 years) and there were 13 female and 9 male patients. Ischemic cerebral infarct constituted the dominant clinical symptom (68.2%) and 3 patients exhibited concomitant cardiac manifestations. Atrial myxoma was diagnosed by echocardiography in all patients. Irregular surface of atrial myxomas was associated with a high risk of embolic events. The patients with myxoma successfully underwent surgery with no mortality recorded. In conclusion, atrial myxomas frequently manifest as cerebral infarction in individuals without cardiovascular risk factors. These tumors more commonly affect the middle cerebral artery. Irregular surface of myxomas appears to be associated with embolic events. Echocardiography may improve the diagnosis and early treatment of atrial myxomas.

Atrial myxoma presenting as infective endocarditis

A 23-year-old Asian student presented to our service with a 1-month history of fever, weight loss of 10 kg, night sweats, fatigue and general malaise. He was previously well with no significant medical or family history. He had a low-grade pyrexia and cardiac auscultation revealed a diastolic murmur consistent with 'tumour plop'. He had no sequelae of endocarditis. He had low-grade pyrexia of 37.7°C, and ECG showed sinus tachycardia at 130 bpm. He had raised inflammatory markers and was started on broad spectrum antibiotics. Blood cultures grew Streptococcus viridans twice. Transthoracic and transo-oesophageal echocardiography revealed a large mobile mass attached to the interatrial septum, suspicious for atrial myxoma, flopping into the left ventricle but not causing left ventricular outflow tract obstruction. All valves looked normal in appearance. He was treated with antibiotics for 2 weeks until inflammatory markers normalised. The patient was referred for cardiothoracic surgery where a large atrial myxoma (5 cm×3 cm) was excised just superior to the mitral valve. It had areas of necrosis and was colonised with S. viridans He had an unremarkable postoperative course and made a complete recovery.

Obstructive Primary Cardiac T-Cell Lymphoma: A Case Report from Senegal

BACKGROUND Cardiac lymphoma is a rare entity, defined by the non-extra cardiac location at diagnosis. CASE REPORT Our patient was a 32-year-old female with no particular medical history, who presented with right heart failure with recurrent ascites and pleural effusion. There was a progressive worsening exertional dyspnea. On admission, examination revealed an irregular tachycardia at 170 beats per minute (bpm) and congestive heart failure. The electrocardiogram scored full tachyarrhythmia by atrial fibrillation with an average ventricular rate of 179 cycles per minute. Doppler echocardiography showed dilatation and systolic dysfunction of the left ventricle. There were dilated atria. We noted a large mass in the right atrium, which was less mobile, heterogeneous, integral with the wall, and filling three quarters of the cavity. It clogged the tricuspid valve in diastole. CT scan showed a tissue process enhanced after contrast injection, occupying the predominant cavities in the right atrium and filling it. Its borders were irregular. The lesion was extended to the posterior mediastinum, in front of the vertebral axis. In addition, there was a thrombosis of the jugular vein and the inferior vena cava. There was no other tumor site noted. The patient died after presenting with cardiovascular shock associated with refractory right heart failure. Pathology examination confirmed T-cell lymphoma. CONCLUSIONS The primitive cardiac lymphoma is an entity of intra-cardiac masses. It is therefore to be considered even if the diagnosis is challenging.

An Atypical Right Atrial Myxoma With Spontaneous Rupture

Typically, cardiac maxomas arise from the interatrial septum at the border of the fossa ovalis in the left atrium, whereas atypical right atrial myxoma, especially with spontaneous rupture, is extremely rare. Here we report the diagnostic evaluation and successful surgical resection of an atypical myxoma with spontaneous rupture arising from the posterior wall of the right atrium in a 34-year-old male.

Risk prediction for emboli and recurrence of primary cardiac myxomas after resection

BACKGROUND

Risk factors for embolism and recurrence of primary cardiac myxoma are not well established. This study aimed to assess the risk factors for embolism and recurrence of cardiac myxoma, as well as the survival of the patients.

METHODS

The medical records of 207 consecutive patients treated for primary cardiac myxoma between September 1988 and October 2014 were retrospectively analyzed. All diagnoses were pathologically confirmed. Data were collected to identify the risk factors influencing the prognosis.

RESULTS

Mean age at surgery was 44.2 ± 15.8 years. Operative mortality (within 30 days of the surgery) occurred in seven patients. Mean follow-up was 9.35 ± 6.55 years. Embolism occurred in 32 (15.5 %) patients before surgery. Multivariate analysis indicated that small (≤ 4.5 cm) myxoma (OR = 5.14; 95 % CI, 2.30-11.94; P < 0.0001) and soft, gelatinous myxoma (OR = 5.84; 95 % CI, 1.91-25.61; P = 0.001) were independently associated with the occurrence of embolism. Ten patients experienced recurrences. After excluding the patients who died within 30 days of surgery, survival was 92.7 % at 10 years. Age, sex, tumor size, cardiopulmonary bypass duration, aortic cross clamp duration, tumor appearance, and pre-operative embolism were not associated with early mortality. Multivariate analysis showed that multicentric myxomas were independently associated with recurrence (OR = 9.45, 95 % CI, 2.15-41.3, P = 0.004).

CONCLUSIONS

The surgical resection of primary cardiac myxoma is associated with excellent long-term survival. Tumors ≤ 4.5 cm and soft tumors were independent risk factors for embolism. Multicentric cardiac myxoma was an independent risk factors for recurrence of myxoma.

Right Atrial Myxoma and Syncope

Patient: Male, 89

Final Diagnosis: Right atrial myxoma

Symptoms: Syncope

Medication: None

Clinical Procedure: Echocardiogram • cardiac MRI

Specialty: Cardiology