Left atrial myxoma and acute myocardial infarction. A dangerous duo in the thrombolytic agent era

Intravenous Thrombolysis for Acute Ischemic Stroke Due to Cardiac Myxoma

Background:

Myxoma may cause systemic embolization and frequently presents as ischemic stroke.

Case Presentation:

There have been debates about whether it is safe to use recombinant tissue plasminogen activator (rt-PA) in patients with cardiac myxoma who referred with ischemic stroke to the hospital’s emergency.

Results:

The patient was a young case of atrial myxoma with initial presentation of acute cerebral infarction symptoms who was treated with intravenous rt-PA with no complications.

Conclusion:

The case provides an evidence of the efficacy and safety of intravenous rt-PA in cases of cardiac myxoma. However, we cannot always expect thrombolytic therapy to be effective, especially in tumor emboli.

Coronary Embolism and Myocardial Infarction: A Scoping Study

Coronary embolism is a cause of acute myocardial infarction (AMI)in which obstructive foci enter the coronary circulation, block normal blood flow and precipitate ischemia. Precise studies focusing on patient population affected, pathophysiological mechanisms, and treatment strategies are scanty, in spite of a reported prevalence estimated at 2.9%. As the understanding of myocardial infarction without evidence of coronary artery disease continues to grow, an in-depth review of this previously seldomly reported subtype of coronary ischemia was in order. Patients suffering coronary embolism are 15 to 20 years younger than traditional AMI patients with a slight predominance towards male sex, which resembles the gender data of the populations affected by non-traditional myocardial infarction in published reports. While the expected prevalence rate of cardiovascular disease risk factors such as hypertension and hyperlipidemia are present, this population also has a relatively high prevalence of atrial fibrillation and valve pathology, especially endocarditis. Initial presentation is indistinguishable from other causes of myocardial infarction however fever is commonly present, when endocarditis with valvular involvement is the primary cause of the coronary embolism. Mechanical thrombectomy is the mainstay of treatment, followed by percutaneous coronary intervention. Mortality is the highest in patients who do not receive targeted treatment for the coronary embolism, particularly if only antimicrobial agents or anticoagulation without thrombolytic agents are employed. The unique features of coronary embolism highlighted in this historical study justify further examination in contemporary patient populations.

Atrial myxoma presenting as a non-ST-segment elevation myocardial infarction

Cardiac myxomas are the most common benign tumors of the heart. We describe the rare phenomenon of myxomatous embolization, resulting in a non-ST-elevation myocardial infarction treated successfully with surgical excision. The routine early use of both transthoracic and transesophageal echocardiography is pivotal in selecting an optimal management strategy for these patients.

Unusual aspects of cardiac myxoma

A cardiac myxoma may manifest as miscellaneous and uncharacteristic presentations. These unusual aspects of cardiac myxomas can be rare clinical presentations, special patient populations, unusual locations, and special pathology, which may lead to a delayed diagnosis, improper checkups, and subsequent untimely treatment, eventually resulting in unexpected poor prognosis. Therefore, the diagnosis of cardiac myxomas can be challenging because of these unusual aspects. In order to get a better understanding of a cardiac myxoma and to facilitate an early diagnosis and proper treatment, the unusual aspects of cardiac myxomas are described here.

The First Manifestation of a Left Atrial Myxoma as a Consequence of Multiple Left Coronary Artery Embolisms

A case of multiple embolisms in the left coronary artery as a rare first manifestation of left atrial myxoma is reported. A patient with embolic myocardial infarction and congestive heart failure was treated by percutaneous aspirations and balloon dilatations. Transesophageal echocardiography disclosed a villous myxoma with high embolic potential. Surgical resection of the tumour, suturing of a patent foramen ovale suture and an annuloplasty of the dilated tricuspid annulus was performed the third day after the admission. Recovery of the documented left ventricular systolic function can be explained by resorption of myxomatous material. The patient was discharged ten days after the surgery.

Acute myocardial infarction caused by left atrial myxoma: Role of intracoronary catheter aspiration

Acute ST-segment elevation myocardial infarction (STEMI) caused by left atrial myxoma is very rare. Catheter-based approaches or thrombolytic therapy are mostly the first step in the management of STEMI with less time delay. We report a case of acute anterior/lateral STEMI caused by a left atrial myxoma. The patient was successfully treated by intracoronary aspiration with an Export aspiration catheter, with excellent distal coronary flow. Intracoronary catheter aspiration in acute myocardial infarction caused by a left atrial myxoma may help to salvage the infarcting myocardium with less time delay.

Left Atrial Myxoma Presenting with Acute Myocardial Infarction

A 38-year-old man presented with an acute anterior myocardial infarction (MI) and was subjected to thrombolysis. Echocardiography and cardiac catheterization revealed a mass in the left atrium that was considered to be a myxoma. The coronary arteries appeared normal on angiography. The left atrial mass was removed surgically without complication. Histopathologic examination confirmed the diagnosis of the myxoma. Coronary embolism secondary to the myxoma was thought to be the cause of the MI.

An Unusual ST Elevation in a Case of Left Atrial Myxoma

Myxomas are the most common and potentially dangerous benign tumours of the heart. They may have either smooth or papillary surfaces and may have thrombus adherent. As both the papillary excrescences and the surface thrombi are friable in nature hence may undergo embolization. We report a case of left atrial myxoma, which underwent excision of the tumour for mitral valve obstructive features. In the immediate postoperative period patient developed ST elevation in lead II, III and aVF. Coronary angiogram revealed normal coronary pattern. Patient was treated with aspirin, heparin and IABP for 48 hours and recovered well. We conclude that there is a tendency for spontaneous recanalization of the obstructed coronary vessels by tumour emboli, hence patient can be managed conservatively.

Left atrial myxoma: a rare nonatherosclerotic cause of acute myocardial infarction

Myocardial infarction from coronary artery embolism is a very rare but potentially lethal sequel of left atrial myxoma. Most atrial myxomas causing myocardial infarction are diagnosed retrospectively after a 2D echocardiogram is performed for assessment of myocardial function after a myocardial infarction. We present a relatively healthy 53-year-old male with anterolateral wall myocardial infarction and 100% occlusion at the proximal part of the obtuse marginal branch of the circumflex coronary artery that was subsequently reperfused. A 2D echocardiogram performed two days later revealed a left atrial mass, which was successfully resected and proven to be a myxoma. No recurrence of the tumor was seen on follow-up after four months. An automatic implantable cardioverter defibrillator was placed for residual ischemic cardiomyopathy with clinical improvement.

Intravenous thrombolysis of occlusion in the middle cerebral and retinal arteries from presumed ventricular myxoma

Background. Although thrombolytic therapy has been shown to be beneficial to stroke patients, the effectiveness of intravenous thrombolysis in ischemic stroke patients with ventricle myxoma is unknown. Case Description. A 22-year-old woman with left hemiplegia was sent to the emergency department at a teaching hospital. The magnetic resonance angiography showed occlusion of the right middle cerebral artery, and the echocardiography showed a mass in the left ventricle. Intravenous recombined tissue plasminogen activator (rt-PA) was administrated, and the postthrombolysis transcranial Doppler exam showed that her right middle cerebral artery was circulative. The patient's condition improved gradually, and no complication was observed up to 16 months of follow-up. Conclusion. Intravenous rt-PA is a reasonable treatment for stroke patients with ventricle myxoma.

Left atrial myxoma associated with acute myocardial infarction and multiple cerebral infarctions: Report of a case

We report a case of left atrial myxoma associated with acute myocardial infarction (AMI) in a 63-year-old man. Percutaneous coronary intervention was performed immediately, and we removed white intracoronary particles by using a thrombectomy catheter. The postinterventional course was uneventful; however, on hospital day 5, pathological examination revealed platelet thrombus and myxomatous tissue from the particles aspirated by thrombectomy catheter, and transesophageal echocardiography showed a gelatinous mass in the left atrium. Based on these findings, we diagnosed AMI caused by coronary embolization from a left atrial myxoma, and excision of the myxoma was scheduled. However, preoperative magnetic resonance imaging revealed multiple subacute cerebral infarctions, and the tumor was successfully excised on hospital day 13. Although coronary embolization induced by cardiac myxoma is rare, it should be considered in a young to middle-aged patient presenting with signs of AMI without coronary risk factors.

An unusual presentation of atrial myxoma in an elderly patient: a case report

Left atrial myxoma is the most common intracardiac tumour. It could be seen in patients between 3–83 years of age, with the majority presenting in fifth decade of life as sporadic cases (90%) and second decade as familial cases (10%) [1]. It is an important source of central nervous system embolism [2]. Elderly patients often present with non specific symptoms that are often overlooked in the absence of a supporting cardiac history which makes an early diagnosis challenging. This case report discusses an unusual presentation of left atrial myxoma in an elderly patient.

Left atrial myxoma presenting with ventricular fibrillation

Coronary artery embolism with myocardial infarction is a very rare and potentially life-threatening complication of left atrial myxoma. We report the case of a 51-year-old male who presented with chest pain. Whilst awaiting medical review in the emergency department, he collapsed and a cardiac monitor revealed ventricular fibrillation. Following successful resuscitation, a 12-lead electrocardiogram demonstrated anterior myocardial infarction that was initially presumed to be secondary to atheromatous coronary disease. An echocardiogram performed before discharge, however, revealed a mass in the left atrium, which was highly suggestive of a myxoma. His subsequent coronary angiogram demonstrated coronary disease limited to a single lesion within a small first obtuse marginal branch of his circumflex coronary artery. He underwent curative surgery, and histology confirmed the diagnosis of myxoma. We have discussed embolic complications of myxoma and the possible reasons for rarity of coronary embolisation. Emphasis is given to the importance of considering other causes of myocardial infarction in relatively young patients and the important role of early echocardiography following myocardial infarction.

Left atrial myxoma presenting as acute inferior wall infarction-a case report

Acute myocardial infarction is a rare form of presentation in patients with left atrial myxoma. With wider availability of echocardiography, more and more patients with atrial myxomas will be diagnosed. This report describes a patient with left atrial myxoma who presented features of acute myocardial infarction and had surgical removal of LA myxoma.

Left atrial myxoma associated with acute myocardial infarction

A 38-year-old male was admitted to our institution with left atrial myxoma complicated with acute myocardial infarction. The patient had no risk factor for coronary artery disease. A transthoracic echocardiographic study revealed the presence in the left atrium of an echogenic, mobile mass, compatible with myxoma. There were no endocrine hyperactivity, any other tumor and family history. Coronary angiography revealed normal coronary arteries and aorto-coronary bypass surgery was not required in this patient. The tumor was successfully removed surgically. In conclusion, there could be no other etiologic possibility identified and therefore left atrial tumor causing coronary embolization and MI was considered the most likely event in this patient.

Myocardial infarction as complication of left atrial myxoma

Although cardiac myxomas are histologically benign, they tend to form emboli and cause intracardiac obstruction, so that they must be classified as potentially fatal tumors of the heart. The probability of arterial embolism is closely correlated with the morphology of the tumor. Thus, villous myxomas are more fragile and form emboli more often. Nuclear spin tomography and echocardiographic cine-mode sequences provide impressive images of the potential for embolism. It appears that coronary embolism may be more frequent in the group of myxoma patients than generally is assumed. These may present as acute myocardial ischemia with the typical clinical symptoms of acute myocardial infarction, as a silent infarct, shock, syncope or as sudden cardiac death. Besides our case report this paper will give an overview on published data on coronary embolism in patients with atrial myxoma. Interestingly there is a tendency for spontaneous recanalization of the obstructed coronary vessels, perhaps because of the tumors' tissue composition. Therefore it is reasonable to perform transoesophageal echocardiography to check out embolic sources like myxoma, when pathogenesis of myocardial infarction remains unclear after coronary angiography.

Clinical features and surgical treatment of cardiac myxoma: report of 18 cases

Myxomas are the most common benign primary cardiac tumors. As many patients with cardiac myxoma suffer from cerebral or systemic embolism, which are serious complications, diagnosis of the tumor is vital. Between 1990 and 2000, 18 patients (6 males, 12 females), aged 24 to 73 years (mean, 55.3 years), were operated on for cardiac myxoma. The most common location of the myxoma was the left atrium (78%), and the transseptal surgical approach was preferred (78%) as it allows total resection of the left atrial myxoma along with its pedicle. Carney complex, a familial autosomal dominant form of atrial myxoma, was not found in any of the patients. There had been no operative or postoperative mortality and morbidity. The mean postoperative follow-up period was 5 years (mean, 1 to 10 years). No recurrence had been seen. We believe that the transseptal approach, in allowing total resection of the myxoma, prevents recurrence.

Left atrial myxoma presenting with myocardial infarction. Case report and review of the literature

Coronary artery embolization is an extremely rare and potentially lethal complication of atrial myxomas. We present a case report and a literature review of this clinical association. A 53-year-old woman presented with an acute infero-lateral myocardial infarction. Coronary angiography performed 1 h after the onset of pain disclosed an abrupt stop and multiple embolization of the peripheral right coronary artery (RCA). A transthoracic echocardiographic study revealed the presence in the left atrium of an echogenic, mobile mass, compatible with myxoma. The tumour was successfully removed surgically 2 weeks later and the patient is doing well one year post operatively.