Left Atrial Myxoma

Case Presentation
dr. Andi Renata Bastario S
Prof. Dr. dr. Peter Kabo, Ph.D, Sp.FK, Sp.JP
 Introduction

• Myxomas are the most common cardiac neoplasm

• Most cardiac myxomas are located in the left atrium
• Most of patient presented with one or two of Triad
Myxomas (Mitral Valve Obstruction, Embolism, and
Constitutional symptoms)
• In Our Case, 52 years old woman presented with
Chest Pain as the primary symptoms
 Patient identity

• Name : Mrs. F
• Date of Birth : 31/12/1965 (52 yo)
• Address : Polewali
• MR : 81.50.61
• Date of Admission : 12/09/2017
 History Taking
• A 52 years old woman was admitted to ER with chest pain
as main complain since 7 days ago, burn-like sensation,
mainly at epigastric area, accompanied by nausea
• She had history of intermittent chest pain for the last 1
year and also complaining fatigue, dyspnea on effort
during last 3 months and sometimes aggravated by lying
on the left side
• She also experienced weight loss and pain at several joints
• There were no history of hypertension, diabetes mellitus,
smoking and cardiac disease inside family
 Physical Examination

• BP: 121/84 mmHg, HR : 80 bpm regular, RR : 28 tpm, T : 36.5 C

• Anemic conjunctiva (+), icterus (-)
• JVP R+2 cmH2O
• Vesicular breath sound, rales at basis of both lungs
• Loud S1, Split S2 (Tumor Plop) diastolic murmur grade 2/4 at apex
• Normal peristaltic movement
• oedema pretibial +/+
 ECG PJT 12/09/2017

Sinus rhythm, heart rate 78 bpm, axis 60,P wave 0,08s, PR int 0,16s , QRS complex 0.08 s. Inverted T III,aVF
Concl: Sinus rhythm, normoaxis, inferior wall ischaemia
 Lab. Findings,12-09-2017

• WBC : 7.6 x 103 /uL • RBG : 145 mg/dl

• PLT : 402 x 103 /uL • PT : 12.4 s
• HB : 10.6 mg/dl • APTT : 24.0 s
 MCV : 72 (80.0 – 97.0) • INR : 1.16
 MCH : 23 (26.5 – 33.5) • CK : 25.99
 MCHC : 31 (31.5 – 35.0) • CK-MB : 13.6
• Ur : 39 mg/dl • Trop-I : <0.01
• Cr : 0.71 mg/dl • Na : 132 mmol
• GOT : 138 mg/dl (<38) • K : 4.7 mmol/l
• GPT : 55 mg/dl (<41) • Cl : 98 mmol/l
Chest X-Ray, 12 sept 2017
• Increase of bronchovascular
marking
• Cardiomegaly with CTI: 0.56
• Blunted right costophrenic angle
• Intact bones

Conclusion :
o Cardiomegaly with sign of
pulmonary congestion
o Right Pleural effusion
Echocardiography
 Echocardiography
• Normal of LV systolic function, EF 68% by TEICH
• Heart chamber dimension: normal cardiac chamber (LVEDd : 4. cm, LA major : 4.8 cm, LA minor : 3.9 cm, RA
major : 4.4 cm, RA minor 3.7 cm , RVDB : 2.1 cm).
Mass with stalk in LA
• LVH (-) (LVMI 69 gr/m2)
• Global normokinetik.
• Normal RV systolic function, TAPSE 1.9 cm
• Valves:
 Mitral: normal movement
 Aorta: 3 cupsid, calsification (-), normal movement
 Tricuspid: Trivial TR
 Pulmonal: PV acct: 89 m/s, mild PH (mPAP: 38 mmHg)
• E/A < 1, eRAP 5-8 mmhg, LVCO 6.45 L/min

Conclusion :
• Normal LV systolic function
• LA Myxoma
• PH mild
• Disfungsi diastolic grade 1
Coronary Angiography
 Coronary Angiography

Diastole Systole
 Coronary Angiography

• Left Main : Normal

• Left Anterior Descending : Myocardial bridging at distal
• Left Circumflex : Normal
• Right Coronary Artery : Normal

• Conclusion : Myocardial Bridging

 Working Diagnosis

 Congestive Heart Failure NYHA II

 Atypical Chest Pain
 Left Atrial Myxoma
 Microcytic Hypochromic Anemia
 Right Pleural Effusion
 Management

• Oxygen 4 LPM/nasal cannula

• Natrium Chloride 0.9% 500cc/24 hours/ intravenous
• Furosemide 40 mg/12 hours/ intravenous
• Lansoprazole 30 mg/24 hours/intravenous
 Plan

• Consult to Cardiothoracic department

• Peripheral Blood Smear, Fe, TIBC
 Follow up

• Patient underwent cardiac surgery on 26-9-2017 for

myxoma excision
• Pathology anatomy result match for cardiac myxoma
• Patient had excellent recovery with symptoms
relieved, stable vital sign and tumor plop sounds
disappeared
• Patient discharged from hospital on 4-10-2017
 Cardiac Tumor

Primary Secondary

30 times more
Very Rare (Incidence common
0,001-0,03%) (Incidence 1,7%-14%
in cancer patient)

69% of them are

Mostly (>80%) benign
pericardial metastasis
50% of them are
Mostly from lung
Myxoma
cancer

Braunwald Heart Disease 10th edition, pg 1863-1871

Braunwald Heart Disease 10th edition, pg 1864
 Myxoma

• Most myxomas (>80%) are found in the left atrium

and in decreasing frequencies in the right atrium,
right ventricle, and left ventricle
• The incidence of cardiac myxoma peaks at 40 to 60
years of age
• female-to-male ratio of approximately 3:1
• Most myxomas occur sporadically but may be
familial (carney syndrome)

Braunwald Heart Disease 10th edition, pg 1864

 Pathophysiology

• The exact origin of myxoma cells remains uncertain

• Possible arise from remnants of subendocardial
cells or from multipotential mesenchymal cells in
the region of the fossa ovalis that can differentiate
along a variety of cell lines
• Myxomas typically form a pedunculated mass
• myxomas appear yellowish, white, or brownish and
are frequently covered with thrombus

Braunwald Heart Disease 10th edition, pg 1864

 Clinical Manifestation

• commonly asymptomatic and the tumor is found as

an incidental finding on two-dimensional
echocardiography
• Most signs and symptoms related to myxoma result
from obstruction of the mitral valve (syncope,
dyspnea, and pulmonary edema), followed by
embolic manifestations and Constitutional
symptoms, known as Triad Myxoma

Braunwald Heart Disease 10th edition, pg 1864

 Clinical Manifestation

• Angina on Left Atrial Myxoma

• Coronary embolization
• Systemic embolization is a known complication of left atrial
myxomas, but coronary embolization is extremely rare with an
incidence of 0.06%
• Coronary blood flow steal
• Highly vascularized atrial myxoma caused coronary steal with
objective evidence of ischemia, no obstructive coronary arteries,
and subsequent resolution after resection
(Kevin et al, left atrial myxoma causing coronary steal, 2015)

Braunwald Heart Disease 10th edition, pg 1864

 Clinical Manifestation

• Angina on myocardial bridging of coronary artery

• Vessels compression during systole, resulting in
hemodynamic changes that may associated with angina,
myocardial ischemia, acute coronary syndrome, left
ventricular dysfunction, arrhythmias and even sudden
cardiac death
(Lee et al. myocardial bridging : an up-to-date review)
 Clinical Manifestation

• On the Physical Findings

• Signs of Congestive Heart Failure
• Increased jugular venous pressure
• Rales on pulmonary auscultation
• Ascites and Hepatomegaly may found
• Lower extremities swelling

Braunwald Heart Disease 10th edition, pg 1864

 Clinical Manifestation

• Cardiac Examination
• Loud S1 due to late closure of mitral valve
• Late P2 depend on Pulmonary Hypertension
• Murmur diastolic mimicking mitral stenosis
• Murmur systolic from mitral regurgitation with valve
damaged
• Tumor Plop after S2

Braunwald Heart Disease 10th edition, pg 1864

 Laboratory Findings

• Abnormal results on laboratory tests that can be

useful may include anemia, elevated serum gamma
globulin, elevated erythrocyte sedimentation rate, and
increased serum C-reactive protein
• Increase of Interleukin 6 (can be used as recurrence
marker)

Braunwald Heart Disease 10th edition, pg 1864

 ECG

• No electrocardiographic (ECG) findings are specific

for myxoma
• 35% myxoma patients had Left Atrial Enlargement
on ECG Findings and rarely arrythmias

Braunwald Heart Disease 10th edition, pg 1864

 Chest X-ray

• Chest radiographic findings are also nonspecific but

include signs of congestive heart failure,
cardiomegaly, and left atrial enlargement
• In some cases the tumor itself may be visible because
of calcification

Braunwald Heart Disease 10th edition, pg 1864

 Imaging study

• Two-dimensional echocardiography should usually

demonstrate a mass in the atrium with the stalk
attached to the intra-atrial septum
• TEE provides specific delineation of the tumor,
including its size and origin
• CT and MRI provide better delineation of the intra-
cardiac mass, the extent of tumor in relation to extra-
cardiac structures, and anatomic definition for
preoperative planning

Braunwald Heart Disease 10th edition, pg 1864

 Cardiac Catheterization

• Can be Helpful when non invasive examination was

not satisfying
• To evaluate coronary blood vessels before surgery

Braunwald Heart Disease 10th edition, pg 1864

 Treatment

• The only definitive treatment of cardiac myxoma is

surgical removal
• Generally, after median sternotomy the myxoma is
excised surgically with the patient under
cardiopulmonary bypass and cardioplegic arrest
• Choice of technique also depends on associated
conditions that need surgical intervention, such as
valve repair or replacement and coronary disease

Braunwald Heart Disease 10th edition, pg 1864

 Recurrency

• Recurrence rates vary but range from 5% to 14%

Braunwald Heart Disease 10th edition, pg 1864

• Thank You