Atrial Myxoma

A lady with
acute SOB
Sammi Pe
Case Presentation
54/F
Cat II
BP 129/69mmHg P 128
Temp 36.9
SpO2 78% ( 100% O2)
Triage : SOB since afternoon, cough
with sputum, mild chest discomfort
What will you

do ?
What further history
need?
What further Hx
Good Past Health
Domestic helper
SOB since ~2 hrs ago
Mild cough with yellowish sputum xdays
become blood stained on AED
No fever
Chest discomfort today ( tightness)
Palpitation +ve
More hx from employer

Mild exertional SOB x several days
Need resting after her work
No fever all along
No Travel hx
Work in HK x ~17yrs
No GI upset/ abd pain
Not on regular medication
Non-smoker, non-drinker
P/E
Alert GCS 15/15
BP 139/78 P 120
RR 48
Sit up for breathing
SpO2 80% on 100% O2
Recheck Temp 37.2
Hstix 13.2
P/E
Chest: AE fair with
bilateral basal crep,
occ wheeze
Abd soft
HS dual, no murmur
No ankle edema
What will you do

next ?
ABC
100% O2 mask
HB set
Blood x CBC, L/RFT, Trop I , Clotting
ECG
i stat ( arterial)
CXR
ECG x 2
i stat (arterial, on 100%O2)

pH
7.398
pCO2 5.39 kPa
pO2 5.8 kPa
BE
0
HCO3 24.9 mmol/L
SO2
79%
Na 141 K 3.5 i Ca 1.21
Hb 14.6
Our Patient
Problem:
Sudden onset SOB
Desaturation even on 100% O2
Type I Resp Failure
What is yr DDx?
Type I Resp Failure

Typically due to V/Q mismatch
PaO2
low (< 60mmHg(8.0kPa))
PaCO2 normal or low
PA-aO2 increased
Parenchymal disease (V/Q mismatch)

Diseases of vasculature and shunts:
right-to-left shunt, pulmonary embolism
interstitial lung diseases: ARDS,
pneumonia, emphysema.
Patient was still

in distress even
on 100% O2
What will you do then?
Patient was put on CPAP

Lasix 40mg iv
BP 110/70
Clinically improved
CXR film A/V.
CXR
What is
yr
Diagnosis
?
APO .
? Other drug(s) to be
considered
? Underlying cause
CCU was consulted
Medications
Nitrates
Vasodilation
Reduced preload
and afterload
Improved CO
Rapid effect
Not prescribed
likely due to BP on
low side
Diuretics
Reduced plasma
volume / preload
Pulmonary
vasodilatation
ACEI
Reduced afterload
Improved CO
Underlying Causes
ACS
HT
Aortic/mitral valve
disease
Arrhythmias
VSD
Cardiomyopathy
Acute myocarditis
Pericardial disease
Atrial myxoma
Echo was
performed
Our case
What is show in
the
Echocardiogram?
CCU input
ECHO:
LA mass ~4cm
Likely atrial
myxoma
Trivial MR/AR
Normal LV size and
EF
Our Patient
APO secondary to large atrial
myxoma
Transfer to CCU then CTSU for further
Mx.
Progress
Emergency excision of atrial myxoma
6x5cm encapsulated LA tumour attached to inter-atrial
septum.
Causing obstruction & pul edema
Bi-atrial exploration + excision of tumour
Extubated on D1
Post-op echo: EF 70%
no PE
Day 0
Day 1
Day 2
Day 3
Day 4
Day 20
PatientwasdischargeonD8andSOPDFU
OnDay20
GoodRecovery,ClassIII,ET3-4FOS
Atrial Myxoma
Background
Most common 1 Heart tumour (40-50%)
90% solitarty and pedunculated
Multiple tumours occur in 50% of familial case
10% familial ( autosomal dominant)

75-85% occur in LA
~25% RA
Attach to fossa ovalis
Symptomatic ~ 70g
140g
Myxoma polypoid, round,

oval in shape
Smooth / lobulated
surface
White/ yellow/
brown
Produce numberus
growth factors and
cytokines e.g.
interleukin-6
Histology
lipidic cells embedded in a vascular
myxoid stroma
In a series of 37 cases,
74% of tumors showed
immunohistochemical expression of
interleukin-6 while
17% had abnormal DNA content
Epidemiology
US ~ 75 case / million autopsies
75% sporadic Female
Mean age 56
15% present as sudden death
tumour embolism, HF, mechanical
obstruction
History
Asymptomatic (20%)
symptomatic
sudden death (15%)
Mechanical interference with cardiac fx

LHF
Exertional SOB
Orthopnea
PND
Pul edema
Postural dizziness
RHF
fatigue
peripheral edema
ascites
systematic (L)
infarct / haemorrhage
of viscera
e.g. CVA
visual loss
embolization
Pulmonary (R)
PE
Pul infarction
Pul HT
Constitutional symptoms : fever, Wt loss, arthralgias, Raynaud ~ 50% of patient due to

interleukin-6 overporduction
Physical
JVP
Loud S1 ( delay mitral valve closure)
Early diastolic sound (Tumor plop)
tumor hit
against the endocardial wall
Diastolic atrial rumble ( obstruction in MV)

MR/ TR ( valvar damage/ prolapse)
DDX
Mitral Regurgitation
Mitral Stenosis
Pul Embolism
Pul HT , primary
Tricuspid Regurgitation
Tricuspid Stenosis
Ix
Lab: ESR, CRP, CBC, serum
interleukin-6
CXR
ECHO
need to differentiate thrombus from myxoma
Thrombus ( in posterior portion, in layers)
Myxoma ( presence of stalk and mobility)
MRI (point of attachment )

CT scan
Treatment
Medical treatment for CHF and
arrhythmia
Surgical excision is the definitive tx
Safe and curative
Recurrence is possible if incomplete
excision
Thank you

Atrial Myxoma

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Atrial Myxoma

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A lady with

What will you

More hx from employer

What will you do

i stat (arterial, on 100%O2)

Type I Resp Failure

Parenchymal disease (V/Q mismatch)

Patient was still

Patient was put on CPAP

CXR film A/V.

10% familial ( autosomal dominant)

Myxoma polypoid, round,

sudden death (15%)

Mechanical interference with cardiac fx

Constitutional symptoms : fever, Wt loss, arthralgias, Raynaud ~ 50% of patient due to

against the endocardial wall

Diastolic atrial rumble ( obstruction in MV)

MRI (point of attachment )

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