A Case of Dyspnea in a Patient with a Previous Coronavirus Disease Infection: Pulmonary is not always the Cause.

Myxoma is the most common benign primary tumor of the heart. Diagnosis of cardiac myxoma is difficult as it presents itself with varying nonspecific symptoms, and an echocardiography can easily diagnose it. Sometimes, it can cause cardiac syncope and thromboembolic events. A woman with a recent infection by severe acute respiratory syndrome coronavirus-2 was admitted to our hospital with respiratory symptoms: dyspnea and tachypnea; cardiac symptoms: atrial fibrillation; and neurological symptoms: syncope. Initially, she performed brain computed tomography (CT) and CT angiography value. Transthoracic echocardiogram and transesophageal echocardiogram showed an atrial mobile mass. Chest X-ray did not show any interstitial lesions. Therefore, urgent cardiac surgery was performed to remove the mass. The histological examination confirmed the presence of a cardiac myxoma. Our experience could show the importance of early diagnosis and prompt surgical treatment to prevent stroke. Copyright:

INTRODUCTION

Myxoma is one of the most common cardiac tumors. Up to 90% of myxomas are located in the left atrium, with most of these tumors involving the atrial septum.[1]

Cardiac myxomas are noncancerous primary tumors of the heart and constitute about 50% of all primary heart tumors. Myxomas occur most often in women patients aged 30–70.[2]

The clinical manifestation of coronavirus disease 2019 (COVID-19) can vary from an asymptomatic course to acute respiratory distress syndrome requiring invasive mechanical ventilation and extracorporeal membrane oxygenation.[3]

Surgeries in patients with a recent COVID-19 are very risky.[45]

CASE REPORT

We present a case of a 66-year-old woman who was admitted to the emergency room with respiratory symptoms: dyspnea and tachypnea, and cardiac symptoms: atrial fibrillation.

Furthermore, she had two syncopal episodes in 24 h before entering the hospital.

The nasopharyngeal swab was negative for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) reverse transcription–polymerase chain reaction, but the patient reported that she had a SARS-COV-2 infection 3 weeks before entering the hospital. The serological test showed a high level of SARS-CoV-2 Ig-G.

The patient also suffered from chronic diseases, such as had arterial hypertension, dyslipidemia, diabetes mellitus, and Hashimoto's thyroiditis.

At the neurological evaluation, the patient did not show any deficit or difficulty in speaking.

The brain computed tomography (CT) and angioCT values were negative.

The transthoracic echocardiography (TTE) has detected an atrial mobile mass that was attached to the interatrial septum with partial prolapse into the left ventricle during systole.

The transesophageal echocardiogram (TEE) confirmed the presence of irregular and protruding pedunculated portion on the mitral valve, which was causing an obstruction on the left ventricular outflow with significantly elevated pulmonary artery hypertension (45 mmHg) [Figure 1 and Video 1]. Mass measuring was 7 cm × 4 cm. Left ventricular systolic function was reduced [Figure 2 and Video 2].

Figure 1

Transesophageal echocardiogram showing the mass during the cardiac cycle

Figure 2

Transesophageal echocardiogram shows a large left atrial mass at the level of the mitral valve

Chests X-ray did not show interstitial lesions. After confirming the absence of active COVID-19 disease, proceeded with the operation.

Anticoagulant and antithrombotic therapies were administered; urgent cardiac surgery was performed and the mass was confirmed as a myxoma [Figure 3].

Figure 3

Postresection left atrial myxoma

Cardiopulmonary bypass was established with conventional mild hypothermia (33.0°C). During a single-aortic cross-clamping, the tumor of the interatrial septum was excised through an oblique and longitudinal atriotomy. Histological examination confirmed cardiac myxoma.

The patient was extubated on the 1st day and then discharged from the intensive care unit (ICU) on the 4th day. She had an uncomplicated postoperative course.

DISCUSSION

Cardiac myxoma is a rare and insidious disease. It often comes with nonspecific symptoms, such as fatigue, fever, myalgia, erythematous rash, arthralgia, weight loss, as well as laboratory abnormalities.[12]

It is a rare cause of brain stroke requiring a thorough investigation to arrive at a diagnosis.

The myxoma could also cause acute paroxysmal dyspnea, syncope from “ball-valve blockade” of the mitral orifice, or mitral insufficiency from interfering with the mitral valve closure or damaging mitral leaflets.[6]

Patients with left atrial myxoma usually present signs and symptoms of thromboembolic events.[1]

Certain conditions must be distinguished from myxomas, such as thrombi, other primary cardiac tumors, metastases, and vegetations.[7]

Even though the TTE, a noninvasive method, is considered the imaging modality of choice for the diagnosis of cardiac myxoma, a transesophageal approach provides a better definition of the location and characteristics of the tumor with a sensitivity of almost 100%.[8]

Two-dimensional echocardiography and color Doppler are the most common approaches used to diagnose myxoma and detect hemodynamic changes.[7]

Cardiac myxomas generally arise from the fossa ovalis of the interatrial septum.

The main problem of the myxomas case is the misdiagnosis. Without the echocardiogram, it is very likely that a diagnosis of myxoma would have been missed and the patient would not have received adequate care.[1]

To ruledout the respiratory sequelae of COVID, other X-ray, a thorough thoracic ultrasound examination was performed.

In this clinical case, a pedicle attached to the left atrial lateral wall might have been the clue to the suspected diagnosis of myxoma.

The perioperative risk was very high due to recent COVID infection, but if surgery had not been performed, the risk would have been even greater.

In consultation with cardiac surgeons, it was decide to perform a short extracorporeal circulation and aortic clamp. They were 42 min and 21 min, respectively. Protective mechanical ventilation methods were used during surgery and during hospitalization in ICU with identification of the driving pressure and best peep. A quick extubation was carried out; respiratory physiotherapy and the patient mobilization were initiated early.

No blood transfusions were performed to minimize the risk of TRALI on lungs affected by recent COVID infection.

CONCLUSIONS

The gold standard for diagnosis of left atrial myxoma remains pathological evidence, but TTE and TEE are essential for proper diagnosis and treatment.[67]

Surgical removal of cardiac mass remains the definitive treatment and is fundamental to achieve the correct diagnosis and to avoid inferior vena cava occlusion or thromboembolic risks.[8]

The ultrasound method increases awareness of this disease and is able to the early diagnosis of such tumors.[19]

The patient outcome was successful with the absence of any overt SARS-CoV-2 manifestations in the postoperative period.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.