Angina pectoris in a patient with protein C deficiency and deep vein thrombosis: thrombus versus myxoma?

A 55-year-old Caucasian man with history of hypertension, diabetes mellitus, protein C deficiency, and deep vein thrombosis presented with typical angina. Both computed tomography and transesophageal echocardiography identified a mobile mass in left atrium but could not differentiate between thrombus and myxoma. A cardiac catheterization with coronary angiography demonstrated tumor neovascularization, suggestive of myxoma. Pathology examination after mass resection confirmed the diagnosis. Patients with myxoma could present with obstructive, embolic, or constitutional symptoms. However, typical angina has never been reported as the primary manifestation. Although being helpful, various noninvasive imaging modalities, including magnetic resonance image, often have limitations to help making a definitive diagnosis, before surgery decision, especially under hypercoagulable condition. In contrast, cardiac catheterization can help not only in differentiation diagnosis but also in detecting possible intracoronary embolization from myxoma. In patients with myxoma complicated with hypercoagulable disorders, anticoagulation will play essential role in long-term care.