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CASE REPORT
Year : 2018  |  Volume : 28  |  Issue : 1  |  Page : 59-60

A Biatrial Myxoma with Triple Ripples


Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Web Publication6-Mar-2018

Correspondence Address:
Dr. Ramachandra Barik
All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcecho.jcecho_47_17

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  Abstract 

Cardiac myxoma is a benign tumor, but it is known for its space-occupying effect at the site of origin and frequent systemic embolization. This case report highlights a biatrial myxoma of interatrial septum who presented with significant tricuspid valve regurgitation, atrial fibrillation, and cardioembolic stroke of the left parietal lobe, i.e., a biatrial myxoma with triple ripples.

Keywords: Atrial fibrillation, biatrial myxoma, embolic stroke, tricuspid valve regurgitation


How to cite this article:
Barik R. A Biatrial Myxoma with Triple Ripples. J Cardiovasc Echography 2018;28:59-60

How to cite this URL:
Barik R. A Biatrial Myxoma with Triple Ripples. J Cardiovasc Echography [serial online] 2018 [cited 2018 Nov 14];28:59-60. Available from: http://www.jcecho.org/text.asp?2018/28/1/59/226679


  Introduction Top


Cardiac myxoma is found most commonly in adult females. The median age at presentation is about 49 years, with wide range in the age of presentation from below the age of 20 years to >90 years. Left atrium is the most common site. About 90% of myxomas are solitary. Biatrial myxoma is rare. Clinical suspicion is difficult because of nonspecific clinical features such as fever, myalgia, abnormal heart sounds, murmurs, and cardioembolic stroke. Echocardiography is reputed for its high sensitive of detection of cardiac myxomas.


  Case Report Top


A 69-year-old female had a massive cardioembolic stroke in the left parietal lobe 2 months earlier. There was a significant improvement of classical right-sided hemiplegia by the time of presentation to us. She was taking acenocoumarol 2 mg once daily, oral glycerin 30 ml three times daily., phenytoin 100 mg t. i. d., and small dose of loop diuretic. A 12-lead electrocardiogram showed atrial fibrillation. Transthoracic echocardiogram and transesophageal echocardiogram unanimously disclosed a classical butterfly wing (so-called dumbbell shaped) intracardiac myxoma with moderate tricuspid valve regurgitation due to direct impingement on tricuspid valve [Figure 1] and [Video 1]. There was no satellite focus. Routine workup showed normal leukocyte count, hematocrit, erythrocyte sedimentation rate, coagulation profile, kidney function test, thyroid function test, normal blood glucose level, and normal chest X-ray. A recent 16-slice computed tomography (CT) scan with contrast enhancement showed large left parietal lobe of cerebral contrast-enhancing space-occupying lesion with midline shift. She was successfully operated for myxoma. The gross pathology of resected bilobed tumor had size of 4 cm × 2 cm with smooth and jelly-like surface with foci of hemorrhage and calcification [Figure 2]. Histopathology using hematoxylin–eosin staining of the excised tumor revealed spindle-shaped cells in a loose myxoid stroma, consistent with the diagnosis of myxoma.
Figure 1: Transthoracic echocardiography in 4-chamber views showed a classical dumbbell-shaped myxoma of 4.1 cm × 3.1 cm sized across the interatrial septum through the foramen ovale. Some specks of hyperechoic spots were marked possibly due to calcification

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Figure 2: The excised tumor mass consisted of 4.1 cm × 3.1 cm mobile right and left atrial myxomas connected by a common stalk which passed through the atrial septum, collectively resembling the shape of a dumbbell (butterfly). Smooth and jelly-like surface with foci of hemorrhage was evident

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  Discussion Top


A dumbbell or butterfly wing or so-called biatrial myxoma or interatrial septal myxoma with biatrial extension usually arises from the left atrial side of the fossa ovalis and prolapses into the right atrium through foramen ovale.[1] Its incidence is <1%–5% of all the intracardiac myxomas.[2],[3],[4] Although it is benign, it is well known for its local space-occupying effect and systemic embolization. A close differential diagnosis is biatrial thrombus crossing a patent foramen ovale, but either biatrial myxoma or straddling thrombus through foramen ovale is a rare diagnosis.[5] Thrombus in this situation may have identifiable causes such as deep vein thrombosis, metastasis, and mitral stenosis.[6] Thrombus is more irregular in shape. Intracardiac thrombus being more fragile usually presents with evidence of pulmonary, systemic embolism, and coronary embolism.[7] It should be removed by wide base resection as soon as possible because of higher frequency of embolization.[8] Echocardiography gives significant number of clues such as the polypoid or smooth surface myxoma, the site of origin, satellite focus, and diastolic blockage of mitral or tricuspid inflow which almost support provisional diagnosis of cardiac myxoma.[9] Contrast-enhanced CT scan of chest or lung scintigraphy would have provided the evidence of silent concomitant pulmonary embolism but has not been done in our case neither before surgery nor after surgery because there was no evidence of pulmonary arterial hypertension and financial limitation.


  Conclusion Top


Impingement of tricuspid valve causing tricuspid valve regurgitation, atrial fibrillation, and cardioembolic stroke was triple ripples of dumbbell-shaped cardiac myxoma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
González-Ferrer JJ, Carnero M, Labayru VL, de Isla LP, Zamorano JL. Left atrial myxoma prolapsing through the foramen ovale. Eur J Echocardiogr 2008;9:595-7.  Back to cited text no. 1
    
2.
Samanidis G, Perreas K, Kalogris P, Dimitriou S, Balanika M, Amanatidis G, et al. Surgical treatment of primary intracardiac myxoma: 19 years of experience. Interact Cardiovasc Thorac Surg 2011;13:597-600.  Back to cited text no. 2
    
3.
Kuroczyński W, Peivandi AA, Ewald P, Pruefer D, Heinemann M, Vahl CF, et al. Cardiac myxomas: Short- and long-term follow-up. Cardiol J 2009;16:447-54.  Back to cited text no. 3
    
4.
Liu D, Dong R. Clinical manifestation and surgical treatment analysis of five cases with biatrial myxoma. Int J Cardiol 2017;228:309-12.  Back to cited text no. 4
    
5.
Sattar A, Win TT, Schevchuck A, Achrekar A. Extensive biatrial thrombus straddling the patent foramen ovale and traversing into the left and right ventricle. BMJ Case Rep 2016;2016:pii: bcr2016216761.  Back to cited text no. 5
    
6.
Lu HT, Nordin R, Othman N, Choy CN, Kam JY, Leo BC, et al. Biatrial thrombi resembling myxoma regressed after prolonged anticoagulation in a patient with mitral stenosis: A case report. J Med Case Rep 2016;10:221.  Back to cited text no. 6
    
7.
Myers PO, Fassa AA, Panos A, Licker M, Bounameaux H, Zender HO, et al. Life-threatening pulmonary embolism associated with a thrombus straddling a patent foramen ovale: Report of a case. J Card Surg 2008;23:376-8.  Back to cited text no. 7
    
8.
Barik R. Letter by Barik regarding article, “Now you see it, now you don't?” Circulation 2016;133:e20.  Back to cited text no. 8
    
9.
Díaz R, Aránguiz E. Asymptomatic left ventricular myxoma incidentally diagnosed by echocardiography. Report of one case. Rev Med Chil 2013;141:1594-7.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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