Systemic embolism from bilateral atrial myxomas

Excerpt

A 77-year-old woman with known hypertension experienced left-side weakness and lost consciousness gradually. On arrival at emergency room, her coma scale was E3V1M4 and National Institutes of Health Stroke Scale score was 18. Computed tomography (CT) scan of the brain demonstrated a small infarct in right internal capsule. Intravenous tissue plasminogen activator was used. Half day later, her left lower limb weakness and consciousness improved gradually. Diffusion-weighted magnetic resonance imaging confirmed multifocal cerebral infarcts. However, the patient presented tachypnea gradually after wakening. High D-dimer of 759 ng/ml was noted. Electrocardiography revealed new ST segment depression and sinus tachycardia. CT of chest revealed an intracardiac left atrial (LA) mass (Fig. 1a) and filling defects in bilateral lower pulmonary arteries (Fig. 1b). Transthoracic echocardiography could not provide clear image. Transesophageal echocardiography revealed a leaf-like pedunculated mass (4.66 cm) with intramural stream of color flow in LA (Fig. 1c, d), and heterogeneous mass was noted in right atrium (RA) (Fig. 1e). Bilateral atrial myxomas were provisionally diagnosed. Deep venous thrombosis was not detected in either lower extremity, and the patient denied any tenderness or swelling of lower extremities. Systemic embolism including cerebral infarct and pulmonary embolism from myxomas was highly suspected. Therefore, surgical approach was suggested. On open heart surgery, a LA mass attached to atrial septum covered with blood clot and a RA mass were excised. Histologic examination confirmed a myxoma with hemorrhagic areas and numerous proliferated blood vessels and stromal cells (Fig. 1f). The size of the myxoma in LA was larger, but the smaller RA myxoma was clotted with much thrombus. The postoperative course was uncomplicated, and she was later discharged.

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