Asymptomatic Left Atrial Myxoma.

Primary tumors of the heart are extremely rare. The most common is the left atrial myxoma. This article presents a case of large asymptomatic left atrial myxoma in an 80-year-old woman. The patient was admitted to the hospital emergency department after a traffic accident. After a performed trauma scan and an echocardiographic examination, a diagnosis of asymptomatic left atrial myxoma was made. The patient was discharged from the hospital with a referral for a consultation at a cardiac surgery center, which the patient did not attend. The treatment of choice for myxomas is surgical removal. The detection of a myxoma usually is considered as an emergency however the tumor described here has the characteristics of myxoma in the complication-free phase. Given the patient's age, reluctance to undergo invasive surgery, and tumor characteristics, it seems that abandoning invasive management in favor of monitoring the patient's condition may be the preferred therapy. Copyright:

INTRODUCTION

Primary tumors of the heart, 50% of which are myxomas, are extremely rare with an incidence 0.0017%–0.19% in autopsies. Left atrial myxomas are the most common and account for 75% of all tumors of this type.[1]

Atrial myxomas have a nonspecific clinical presentation, which makes their diagnosis challenging especially in elderly patients. With the emergence of novel imaging techniques, the detection of cardiac myxomas has increased among the elderly.[2]

Asymptomatic courses are infrequently observed and usually seen in patients with small tumors.

Herein, we present a case of a large left atrial myxoma in an asymptomatic 80-year-old patient.

CASE REPORT

An 80-year-old obese woman with type 2 diabetes mellitus was admitted to the hospital emergency department (ED) after a traffic accident. A trauma scan was performed, which revealed an explosive fracture of the L4 vertebral body and an oval solid lesion in the left atrial lumen measuring 46 mm × 40 mm × 54 mm (AP × RL × CC) with a soft-tissue density of 30–45 jH with small calcifications [Figure 1]. Otherwise, the patient had no significant abnormalities in imaging and laboratory tests. The result of bedside echocardiography in the ED raised the suspicion of left atrial myxoma.

Figure 1

Computed tomography of chest (trauma scan). Computed tomography revealed an oval solid lesion in the left atrial lumen measuring 46 mm × 40 mm × 54 mm (AP × RL × CC) with a soft-tissue density of 30–45 jH with small calcifications

According to the patient's medical history, the patient was self-reliant without symptoms of heart failure, without edema, dyspnea, chest pain and palpitations, and denied any syncope or fainting. She noted decreased exercise tolerance over the past 3 years.

On physical examination, auscultation over the lung fields revealed a symmetrical alveolar murmur, without additional auscultatory phenomena. BP 125/60 mmHg, HR 83/min, gallop rhythm, without pathological murmurs on auscultation in different positions.

Electrocardiogram showed regular sinus rhythm, intermediate heart axis, flat-negative T waves in V5, V6 leads.

Transthoracic echocardiography was repeated in the echocardiography laboratory. The size of the heart cavities was normal except for moderate enlargement of the left atrium, which had an area of 30.2 cm2. A left atrial nodule, approximately 40 mm in diameter, attached to the atrial septum and not affecting mitral valve function was seen [Figure 2 and Supplementary Material 1], the mitral inflow profile on continuous Doppler showed no evidence of left atrial venous stenosis.

Figure 2

Echocardiographic assessment of atrial myxoma. Transthoracic echocardiogram in the parasternal long-axis four chambers view, showing the left atrial myxoma (4.21cm × 4.03cm) adjacent to the atrial septum

A provisional diagnosis of asymptomatic left atrial myxoma was made.

The perioperative risk was estimated at 2.66% (EuroSCORE II). The patient was discharged from the hospital with a referral for a consultation in a cardiac surgery center, which the patient did not attend.

DISCUSSION

The left atrial myxoma can occur in all age groups, but is typically seen in women between the third and sixth decades of life. It is rarely detected in the elderly as in the case of the described patient.[23]

Most patients with left atrial myxoma present with one or more of the characteristic triad of symptoms: Symptoms of mitral valve stenosis, peripheral embolism, or systemic symptoms Table 1. These symptoms depend on the size, location, and mobility of the tumor. On physical examination, an early diastolic murmur (“tumor plop”) can be heard in approximately one-third of patients with myxoma.[1]

Table 1

Characteristics of the triad of symptoms seen in patients with left atrial myxoma

	Symptoms of mitral valve obstruction	Symptoms of peripheral embolism	Systemic symptoms
Incidence	Most common, occurring in 54%-95% of patients	10%-45% of patients	Up to 90% of patients
Characteristics	Dyspnea, weakness, palpitations, cough, pulmonary edema, syncope and even sudden death (due to complete obstruction of the mitral valve by myxoma or coronary artery occlusion)	>2/3 of embolisms migrate to the cerebral circulation, but they are also observed in other locations	Muscle pain, weakness, joint pain, fever, weight loss, clubbing of the fingers, Raynaud’s sign

Tumors as large as in the patient described are rarely asymptomatic.[345]

When a cardiac myxoma is suspected, echocardiography is the diagnostic method of choice. It is an easily accessible, repeatable test and is not associated with the risk of tumor fragmentation and embolization.[6]

The differential diagnosis of a left atrial mass should include a thrombus, which may be difficult to distinguish from myxoma on echocardiography. However, a thrombus usually originates from the left atrial appendage or is attached to the posterior wall of the left atrium and occurs in patients with established atrial fibrillation.

The transthoracic examination might be extended by transesophageal echocardiography which provides better visualization of the atria, atrial septum, and ventricles of the heart. Moreover, it can be particularly helpful in differential diagnosis by detecting morphologic features of the lesion.

The lack of history of arrhythmia in the presented patient, the Computed tomography image and the attachment of the lesion to the atrial septum may support the diagnosis of left atrial myxoma in this case.[1]

The treatment of choice for myxomas is surgical removal. Due to the possible embolic complications or sudden death that can occur due to complete mitral valve obstruction or coronary artery occlusion, asymptomatic tumors are also usually subjected to surgery. Up to 8% of patients with cardiac myxoma die suddenly while awaiting surgery.[5] According to the available literature, the mortality during surgery is low (0%–3%) and the mortality after surgery ranges from 0% to 12%.[57] Recurrent myxomas have been described; however, the overall risk of recurrence for sporadic tumors is only 1%–3%.[1]

Although the detection of a myxoma usually is considered an emergency, the presence of immobile, nonobstructive, well-circumscribed, and calcified myxomas with a low risk of mitral valve obstruction and peripheral embolism may represent an exception to traditional therapeutic management. This is based on the assumption that myxomas in patients with this particular tumor presentation may exhibit a quiescent phase, free of complications.[248] In elderly patients with comorbidities, surgery is associated with a significantly increased risk of death of up to 23.5%.[9]

CONCLUSIONS

Given the patient's advanced age, reluctance to undergo invasive surgery, the asymptomatic nature of the tumor, and the presence of calcifications that reduce the growth potential of a myxoma and the risk of peripheral embolism,[10] it appears that abandoning invasive therapeutic management and regularly monitoring the patient's condition is the preferred management in this situation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand 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.