A Case Report of a Large Left Atrial Myxoma with Unusual Attachment and Simultaneous Embolization to the Brain

AUTHORS

Atefeh Ghareghani 1 , Omid Esmaeili 2 , Marzieh Nikparvar ORCID 1 , * , Hossein Montazerghaem ORCID 1 , Tasnim Eghbal Eftekhaari ORCID 3

1 Cardiovascular Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

2 School of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

3 Molecular Medicine Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

How to Cite: Ghareghani A , Esmaeili O , Nikparvar M, Montazerghaem H , Eghbal Eftekhaari T. A Case Report of a Large Left Atrial Myxoma with Unusual Attachment and Simultaneous Embolization to the Brain, Hormozgan Med J. Online ahead of Print ; 24(2):e100072. doi: 10.5812/hmj.100072.

ARTICLE INFORMATION

Hormozgan Medical Journal: 24 (2); e100072
Published Online: June 8, 2020
Article Type: Case Report
Received: December 21, 2019
Revised: April 29, 2020
Accepted: May 5, 2020
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Abstract

Introduction: Cardiac myxomas are the most common primary tumors of the heart with high embolic potential.

Case Presentation: We present a young man with progressing stroke and atrial myxoma in an unusual site from the left upper pulmonary vein.

Conclusions: Intravenous (IV) thrombolysis can be safe in patients with intracardiac myxoma and CNS embolization after good case selection. However, further studies are needed for better decision-making.

Copyright © 2020, Hormozgan Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Introduction

Primary cardiac tumors are very rare (1) and have a high embolic potential, including embolization of the cerebral vessels (2). Cardiac myxomas are the most common primary tumors of the heart. These tumors are most commonly found in the left atrium, followed by the right atrium and are usually attached to the interatrial septum. The incidence of this tumor peaks at 40 to 60 years of age with a female preponderance (1).

Cerebral infarction is a rare presentation of myxomas (3). A very small number of cases of administration of IV thrombolysis in this situation have been previously reported (4, 5).

2. Case Presentation

A 36-year-old man presented with facial deviation and left-sided hemiparesis and transient decrease in the level of consciousness for one hour before hospitalization.

He had no significant past medical history. He was a cigarette smoker and addicted to opium and marijuana.

On admission, his blood pressure was 100/70, and his heart rate was 80 beats per minute with sinus rhythm. Neurological examination showed normal mental status and left central facial palsy with slurred speech. Muscle power was 3/5 in the left upper and lower extremities. Plantar reflex was upward on the left side and downward on the right side.

The rest of the physical examination was unremarkable. During hospitalization, serial physical examinations were in favor of progressing stroke.

An emergency brain CT scan without contrast was obtained. No ischemic or hemorrhagic lesion was detected on the CT scan. IV thrombolysis was administered with the impression of a stroke in evolution by the neurologist. Alteplase with a dose of 0.9 mg/kg, 90% in bolus dose, and remnant over 1 hour via IV line was infused.

The patient's symptoms alleviated on the second day. Cardiologic consult was done to evaluate the risk factors for embolic cerebrovascular accident (CVA).

A large heterogeneous mobile mass with the possibility of attachment to the lateral wall of the left atrium was detected on transthoracic echocardiography 2D (Figure 1).

2D transthoracic echocardiography shows a large heterogeneous mass with the possibility of attachment to the lateral wall of the left atrium
Figure 1. 2D transthoracic echocardiography shows a large heterogeneous mass with the possibility of attachment to the lateral wall of the left atrium

LVEF (left ventricular ejection fraction) and other parameters were normal, so a transesophageal echocardiography (TEE) was recommended by the echocardiographic fellow.

TEE was performed and showed a large convoluted mass with an area of at least 6.5 cm2, but no definite stalk attachment was detected (Figure 2).

Transesophageal echocardiography shows a heterogenous convoluted mass with an area of at least 6.5 cm2 protruding to the left ventricle through the mitral valve
Figure 2. Transesophageal echocardiography shows a heterogenous convoluted mass with an area of at least 6.5 cm2 protruding to the left ventricle through the mitral valve

The patient was a candidate for cardiac surgery to prevent the obstruction of the left atrium or other embolic events.

In the same hospital, total mass excision was done by the surgeon, and the mass was sent for histopathological examination. The post-operative diagnosis was a large left atrial myxoma with attachment to the origin of the left upper pulmonary vein.

3. Discussion

In all patients with a presentation of embolization, cardiac origin should be considered as a possible cause (3).

Primary cardiac tumors are very rare, and more than 80% of them are benign. Myxoma is the most common benign tumor in adults (1).

More than 80% of the myxomas are found in the left atrium, followed by the right atrium (10% - 20%) and the right and left ventricles with peaks at 40 - 60 years of age and a female to male ratio of 3:1. Myxomas are usually attached to the interatrial septum close to the fossa ovalis (1).

Studies show high embolic potential of intracardiac tumors, 19.8% preoperative, 35% of all LA myxomas, and 10.2% of all commonly have a CNS effect (2, 6).

Some retrospective studies found no relationship between mortality or embolic event and implantation site (2). Other studies showed that atypical location independently associates with an increased risk of embolic complications (5). Unusual site attachment was reported in a few cases. For example, attachment to Acute myeloid leukemia AML, lymphoid-associated antigens LAA, junction of the lateral atrial wall, and mitral annulus have been reported (7, 8).

In our case, the myxoma was attached to the origin of the left upper pulmonary vein.

Intravenous thrombolysis is an acceptable therapy for ischemic stroke within 3.5 - 4 hours of onset of symptoms (7). However, no guideline has discussed this treatment option in patients with embolic stroke caused by cardiac tumors.

There are a few case reports of administering IV thrombolysis and its outcomes in patients with atrial myxoma and stroke (4, 5, 9-14).

Some have reported successful thrombolysis (10-12, 14), while others have reported complications (5, 12).

In our case, the patient was a young male presenting with stroke in evolution. In this case, IV thrombolysis was safe and effective without any complication. Unusual attachment site of the myxoma to the origin of the left upper pulmonary vein was found after echocardiography and cardiac surgery as a potential cause of embolization.

A review of the case reports in Table 1 shows that using IV thrombolysis is safe in patients with intracardiac myxoma and CNS embolization after good case selection. However, further studies are needed for better decision-making.

Table 1. Reviewed Case Reports Using IV Thrombolysis in Patients with Stroke due to Cardiac Myxoma
ReferenceAge/SexYearOSTTICHOutcome
Chong et al. (12)74/F2005180YesAphasia
Ibrahim et al. (9)51/M200684NoComplete recovery
Ong and Chang (10)22/F2010125NoNo complication
Nagy et al. (11)26/M2009105NoMinimal hand weakness
Nishimura et al. (13)72/M2010100NoLt lower extremity weakness
Abe et al. (14)70/M201132NoComplete recovery
Sun et al. (4)45/M2011172NoMotor aphasia and right hemiparesis
Kulkarni et al. (5)69/F201490YesMild distal left hand weakness
This case36/M2017120NoComplete recovery

Abbreviation: OSTT, onset of symptoms to thrombolytic therapy.

Footnotes

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