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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 32  |  Issue : 2  |  Page : 116-118

Asymptomatic left atrial myxoma


1 Department of Cardiology, Hypertension and Internal Diseases, Students' Scientific Group of Cardiology, Mazowiecki Szpital Bródnowski, Warsaw, Poland
2 Department of Sports Cardiology and Noninvasive Cardiovascular Imaging, Medical University of Warsaw, Warsaw, Poland

Date of Submission14-Sep-2021
Date of Decision23-Dec-2021
Date of Acceptance08-Jan-2022
Date of Web Publication17-Aug-2022

Correspondence Address:
Aleksandra Wilk
Department of Cardiology, Hypertension and Internal Diseases, Mazowiecki Szpital Bródnowski, ul. Kondratowicza 803-242, Warsaw
Poland
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcecho.jcecho_70_21

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  Abstract 


Primary tumors of the heart are extremely rare. The most common is the left atrial myxoma. This article presents a case of large asymptomatic left atrial myxoma in an 80-year-old woman. The patient was admitted to the hospital emergency department after a traffic accident. After a performed trauma scan and an echocardiographic examination, a diagnosis of asymptomatic left atrial myxoma was made. The patient was discharged from the hospital with a referral for a consultation at a cardiac surgery center, which the patient did not attend. The treatment of choice for myxomas is surgical removal. The detection of a myxoma usually is considered as an emergency however the tumor described here has the characteristics of myxoma in the complication-free phase. Given the patient's age, reluctance to undergo invasive surgery, and tumor characteristics, it seems that abandoning invasive management in favor of monitoring the patient's condition may be the preferred therapy.

Keywords: Cardiac surgery, diagnostic imaging, geriatric assessment, myxoma


How to cite this article:
Tetera W, Wilk A, Król W, Braksator W. Asymptomatic left atrial myxoma. J Cardiovasc Echography 2022;32:116-8

How to cite this URL:
Tetera W, Wilk A, Król W, Braksator W. Asymptomatic left atrial myxoma. J Cardiovasc Echography [serial online] 2022 [cited 2022 Dec 6];32:116-8. Available from: https://www.jcecho.org/text.asp?2022/32/2/116/353856




  Introduction Top


Primary tumors of the heart, 50% of which are myxomas, are extremely rare with an incidence 0.0017%–0.19% in autopsies. Left atrial myxomas are the most common and account for 75% of all tumors of this type.[1]

Atrial myxomas have a nonspecific clinical presentation, which makes their diagnosis challenging especially in elderly patients. With the emergence of novel imaging techniques, the detection of cardiac myxomas has increased among the elderly.[2]

Asymptomatic courses are infrequently observed and usually seen in patients with small tumors.

Herein, we present a case of a large left atrial myxoma in an asymptomatic 80-year-old patient.


  Case report Top


An 80-year-old obese woman with type 2 diabetes mellitus was admitted to the hospital emergency department (ED) after a traffic accident. A trauma scan was performed, which revealed an explosive fracture of the L4 vertebral body and an oval solid lesion in the left atrial lumen measuring 46 mm × 40 mm × 54 mm (AP × RL × CC) with a soft-tissue density of 30–45 jH with small calcifications [Figure 1]. Otherwise, the patient had no significant abnormalities in imaging and laboratory tests. The result of bedside echocardiography in the ED raised the suspicion of left atrial myxoma.
Figure 1: Computed tomography of chest (trauma scan). Computed tomography revealed an oval solid lesion in the left atrial lumen measuring 46 mm × 40 mm × 54 mm (AP × RL × CC) with a soft-tissue density of 30–45 jH with small calcifications

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According to the patient's medical history, the patient was self-reliant without symptoms of heart failure, without edema, dyspnea, chest pain and palpitations, and denied any syncope or fainting. She noted decreased exercise tolerance over the past 3 years.

On physical examination, auscultation over the lung fields revealed a symmetrical alveolar murmur, without additional auscultatory phenomena. BP 125/60 mmHg, HR 83/min, gallop rhythm, without pathological murmurs on auscultation in different positions.

Electrocardiogram showed regular sinus rhythm, intermediate heart axis, flat-negative T waves in V5, V6 leads.

Transthoracic echocardiography was repeated in the echocardiography laboratory. The size of the heart cavities was normal except for moderate enlargement of the left atrium, which had an area of 30.2 cm2. A left atrial nodule, approximately 40 mm in diameter, attached to the atrial septum and not affecting mitral valve function was seen [Figure 2] and [Supplementary Material 1], the mitral inflow profile on continuous Doppler showed no evidence of left atrial venous stenosis.
Figure 2: Echocardiographic assessment of atrial myxoma. Transthoracic echocardiogram in the parasternal long-axis four chambers view, showing the left atrial myxoma (4.21cm × 4.03cm) adjacent to the atrial septum

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A provisional diagnosis of asymptomatic left atrial myxoma was made.

The perioperative risk was estimated at 2.66% (EuroSCORE II). The patient was discharged from the hospital with a referral for a consultation in a cardiac surgery center, which the patient did not attend.


  Discussion Top


The left atrial myxoma can occur in all age groups, but is typically seen in women between the third and sixth decades of life. It is rarely detected in the elderly as in the case of the described patient.[2],[3]

Most patients with left atrial myxoma present with one or more of the characteristic triad of symptoms: Symptoms of mitral valve stenosis, peripheral embolism, or systemic symptoms [Table 1]. These symptoms depend on the size, location, and mobility of the tumor. On physical examination, an early diastolic murmur (“tumor plop”) can be heard in approximately one-third of patients with myxoma.[1]
Table 1: Characteristics of the triad of symptoms seen in patients with left atrial myxoma

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Tumors as large as in the patient described are rarely asymptomatic.[3],[4],[5]

When a cardiac myxoma is suspected, echocardiography is the diagnostic method of choice. It is an easily accessible, repeatable test and is not associated with the risk of tumor fragmentation and embolization.[6]

The differential diagnosis of a left atrial mass should include a thrombus, which may be difficult to distinguish from myxoma on echocardiography. However, a thrombus usually originates from the left atrial appendage or is attached to the posterior wall of the left atrium and occurs in patients with established atrial fibrillation.

The transthoracic examination might be extended by transesophageal echocardiography which provides better visualization of the atria, atrial septum, and ventricles of the heart. Moreover, it can be particularly helpful in differential diagnosis by detecting morphologic features of the lesion.

The lack of history of arrhythmia in the presented patient, the Computed tomography image and the attachment of the lesion to the atrial septum may support the diagnosis of left atrial myxoma in this case.[1]

The treatment of choice for myxomas is surgical removal. Due to the possible embolic complications or sudden death that can occur due to complete mitral valve obstruction or coronary artery occlusion, asymptomatic tumors are also usually subjected to surgery. Up to 8% of patients with cardiac myxoma die suddenly while awaiting surgery.[5] According to the available literature, the mortality during surgery is low (0%–3%) and the mortality after surgery ranges from 0% to 12%.[5],[7] Recurrent myxomas have been described; however, the overall risk of recurrence for sporadic tumors is only 1%–3%.[1]

Although the detection of a myxoma usually is considered an emergency, the presence of immobile, nonobstructive, well-circumscribed, and calcified myxomas with a low risk of mitral valve obstruction and peripheral embolism may represent an exception to traditional therapeutic management. This is based on the assumption that myxomas in patients with this particular tumor presentation may exhibit a quiescent phase, free of complications.[2],[4],[8] In elderly patients with comorbidities, surgery is associated with a significantly increased risk of death of up to 23.5%.[9]


  Conclusions Top


Given the patient's advanced age, reluctance to undergo invasive surgery, the asymptomatic nature of the tumor, and the presence of calcifications that reduce the growth potential of a myxoma and the risk of peripheral embolism,[10] it appears that abandoning invasive therapeutic management and regularly monitoring the patient's condition is the preferred management in this situation.

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.
Reynen K. Cardiac myxomas. N Engl J Med 1995;333:1610-7.  Back to cited text no. 1
    
2.
Vasquez A, Sethi G, Maximov M, Marcus FI. Atrial myxomas in the elderly: A case report and review of the literature. Am J Geriatr Cardiol 2004;13:39-44.  Back to cited text no. 2
    
3.
Lin Y, Xiao J, Chen J, Hong J, Peng H, Kang B, et al. Treating cardiac myxomas: A 16-year Chinese single-center study. J Cardiovasc Med (Hagerstown) 2016;17:44-53.  Back to cited text no. 3
    
4.
Bire F, Roudaut R, Chevalier JM, Quiniou G, Dubecq S, Marazanoff M, et al. Myxomes cardiaques chez le sujet âgé de plus de 75 ans. A propos de 19 observations [Cardiac myxoma in patients over 75 years of age. Report of 19 cases]. Arch Mal Coeur Vaiss 1999;92:323-8.  Back to cited text no. 4
    
5.
Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Medicine (Baltimore) 2001;80:159-72.  Back to cited text no. 5
    
6.
St John Sutton MG, Mercier LA, Giuliani ER, Lie JT. Atrial myxomas: A review of clinical experience in 40 patients. Mayo Clin Proc 1980;55:371-6.  Back to cited text no. 6
    
7.
Lukács L, Lengyel M, Szedö F, Haán A, Nagy L, Thomka I, et al. Surgical treatment of cardiac myxomas: A 20-year follow-up. Cardiovasc Surg 1997;5:225-8.  Back to cited text no. 7
    
8.
Kay JF, Chow WH. Long-term survival of quiescent left atrial myxoma in an elderly patient. Am J Geriatr Cardiol 2002;11:165-8.  Back to cited text no. 8
    
9.
Boyacioglu K, Donmez AA, Aksut M, Akdemir, I, Ketenciler, S, Adademir T, et al. Surgical management of cardiac myxomas in elderly patients. BMB 2016;1:1-5.  Back to cited text no. 9
    
10.
Roberts WC. Primary and secondary neoplasms of the heart. Am J Cardiol 1997;80:671-82.  Back to cited text no. 10
    


    Figures

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