Case Report
 

By Dr. Antonella Ragusa , Dr. Carmelo Maugeri , Dr. Giuseppe La Rocca , Dr. Sandra Calabrese , Dr. Giovanni Salici , Dr. Anna Romeo , Prof. Rosaria Sorace , Dr. Rocco Romeo
Corresponding Author Dr. Antonella Ragusa
Operative Unit of Cardiology, Giarre Hospital , - Italy
Submitting Author Dr. Antonella Ragusa
Other Authors Dr. Carmelo Maugeri
Cardiology Operative Unit, Giarre Hospital, - Italy

Dr. Giuseppe La Rocca
Cardiology Operative Unit, Giarre Hospital, - Italy

Dr. Sandra Calabrese
Cardiology Operative Unit, Giarre Hospital, - Italy

Dr. Giovanni Salici
Cardiology Operative Unit, Giarre Hospital, - Italy

Dr. Anna Romeo
Geriatric Operative Unit - University of Catania Cannizzaro Hospital , - Italy

Prof. Rosaria Sorace
Geriatric Operative Unit - University of Catania Cannizzaro Hospital , - Italy

Dr. Rocco Romeo
Cardiology Operative Unit, Giarre Hospital, - Italy

CARDIOLOGY

Left Atrial Myxoma, Stroke

Ragusa A, Maugeri C, La Rocca G, Calabrese S, Salici G, Romeo A, et al. An Unusual Cause of Cerebral Ischemia in the Elderly: Left Atrial Myxoma. WebmedCentral CARDIOLOGY 2011;2(3):WMC001735
doi: 10.9754/journal.wmc.2011.001735
No
Submitted on: 10 Mar 2011 01:10:02 PM GMT
Published on: 11 Mar 2011 10:25:18 PM GMT

Abstract


Intracardiac primary tumors are rare conditions. The 75% of them are benign, the 25% malignant and approximately 50% are myxomas in adults. About 75% of atrial myxoma arise in left atrium, while right atrial myxomas occurring only in the 15-20% of all cases as discussed elsewhere [1-3].  The symptoms are atypical and higly variable, often they may remain asymptomatic as discussed by Yuce [4].  According their size, mobility and location,  myxomas may present lung congestion, syncope, sudden death due to thrombo – embolic phenomenon, while exertional dyspnea, syncope or sudden death are caused by  valve obstruction, as discussed elsewhere [1, 5, 6-7]. It has been reported by Uner and Lee, that neurologic complication are associated with cardiac myxoma in the 26% to 45% of patients with cerebral embolic infarct being the most frequently event observed [8-9]. Furtheremore constitutional symptoms  like fever, weight loss, arthralgias, Raynaud’s phenomenon, anaemia, hypergammaglobulinemia, elevated erythrocyte sedimentation rate are related to the production of interleukin 6 as discussed by Kanda.  [10].  5 % of patients with cardiac myxoma may moreover show the simultaneous presence of multiple genetical disorders. This clinical condition is known as “Carney Complex”. The clinical manifestation of this syndrome could present skin pigmentary abnormalities (lentigines or blue nevi), multiple cardiac myxomas at a young age, endocrine tumors, endocrine overactivity, less frequently schwannomas, or multiple myxomas involving breast, skin, oropharynx or female genital tract as discussed elsewhere[11-12]

Echocardiography is the standard diagnostic technique and the surgical removal is the recommended therapy, as is it usual curative, as discussed by  Reynen [2].  

Introduction


A 76 years old male was admitted to our hospital on March  2005 for acute cerebral ischemia. He was suffering from hypertension, diabetes, chronic cerebral vascular disease. He underwent about 15 years ago aortic-femoral arteries bypass and left carotid artery endoarteriotomy. During the examination the patient presented with a systolic blood arterial pressure of 140 mmHg and a diastolic of 80 mmHg, normal heartbeat, with a mitralic 3/6 Levine systolic murmur. He presented skin pigmentary abnormalities.  Electrocardiogram was normal. Laboratory data was within normal limits. Chest X-ray was normal. Cerebral tomography revealed a severe hypodensity in the right cortical-subcortical area related to acute ischemia (figure 1). Routine transthoracic echocardiogram revealed a giant echogenic pediculated left atrial mass (10 cm x 5 cm), arising to the base of interatrial septum prolapsing through the mitral  valve  into the left ventricle during diastole (figure 2). Stabilizing  patient’s clinical conditions, the mass was surgically removed. The pathologic analysis confirmed the echocardiographic suspect of myxoma (figure 3)

At the three months  follow-up echocardiographic examination was normal. Magnetic cerebral resonance showed a chronic ischemic disease and at  the clinic evaluation the signs of cerebral ischemia persisted with a left emiparesis.  Genetic evaluation wasn’t performed because of the patient’s refusal.   

Case Report(s)


This clinical case emphasizes the importance of cardiac evaluation in case of stroke in the elderly. Atrial myxomas are rare, often asymptomatic. Myxoma is a rare case of stroke. Neurologic complications are associated with cardiac myxoma in same patient with myxoma and when they occur, frequently present with cerebral infarction. Stroke is due to cerebral embolism of the left atrial mass The mobility not the size of the myxoma appears to be related to embolic potential. In this case diagnosis was occasionally made by routine transthoracic echocardiogram. Ecocardiography provided a good detection of the massa and was helpful to surgery planning.

Discussion


Neurologic complication can be the initial manifestation of atrial myxoma in the elderly. Prompt diagnosis is of significance to prevent recurrent complications.

In case of stroke and peripheral embolism,  a cardiologic examination is important and transthoracic echocardiogram is necessary to exclude a cardiac myxoma.               &nb sp;    

Conclusion


1. Azevedo O, Almeida J, Nolasco T, Medeiros R, Casanova J, Bartosch C, Pinho P. Massive right atrial myxoma presenting as syncope an exertional dyspnea: case report. Cardiovasc Ultrasound 210 Jun 18; 8:23.
2. Reynen K. Cardiac myxomas. N Engl J Med. 1995;333:1610–7.
3. Jallad N,Parikh R, Albareqdar E, Al-Dehneh A, Goldstein J, Shamoon F, Connolly MW. Concurrent primary cardiac tumors of differing histology and origin. Tex Heart Inst J 2009;36(6):591-3.
4. Yuce M, Dagdelen S, Ergelen M, Eren N, Caglar N. A huge obstructive myxoma located in the right heart without causing any symptom. Int J Cardiol. 2007;114:405–6.
5. Alsafwah S, Lababidi Z. Recurrent pulmonary embolism originating from right atrial myxoma. J Am Soc Echocardiogr. 2001;14:305–7.
6. Bilku RS, Loubani M, Been M, Patel RL. Massive right atrial myxoma causing exertional dyspnoea. Eur J Echocardiogr. 2008; 9:130–2.
7. Surabhi SK, Fasseas P, Vandecker WA, Hanau CA, Wolf NM. Right atrial myxoma in a patient presenting with syncope. Tex Heart Inst J. 2001;28:228–9.
8. Uner A, Dogan M, Sal E, Peker E. Stroke and recurrent peripheral embolism in left atrial myxoma. Acta Cardiol 2010 Feb; 65 (1):101-3.
9. Lee VH, Connolly HM, Brown RD Jr. Central nervous system manifestation of cardiac myxoma. Arch Neurol. 2007 Aug; 64(8):1115-20.
10. Kanda T, Takahashi T. Interleukin-6 and cardiac myxoma. Am J Cardiol. 1994;74:965–7.
11. Bertherat J. Carney complex (CNC). Orphanet J Rare Dis. 2006 Jun 6;1:21.
12. Neragi-Miandoab S, Kim J, Vlahakes GJ. Malignat tumors of the heart: a review of tumor type, diagnosis and therapy. Clin Oncol (R Coll Radiol) 2007 Dec; 19(10):748-56

References


1. Azevedo O, Almeida J, Nolasco T, Medeiros R, Casanova J, Bartosch C, Pinho P. Massive right atrial myxoma presenting as syncope an exertional dyspnea: case report. Cardiovasc Ultrasound 210 Jun 18; 8:23.
2. Reynen K. Cardiac myxomas. N Engl J Med. 1995;333:1610–7.
3. Jallad N,Parikh R, Albareqdar E, Al-Dehneh A, Goldstein J, Shamoon F, Connolly MW. Concurrent primary cardiac tumors of differing histology and origin. Tex Heart Inst J 2009;36(6):591-3.
4. Yuce M, Dagdelen S, Ergelen M, Eren N, Caglar N. A huge obstructive myxoma located in the right heart without causing any symptom. Int J Cardiol. 2007;114:405–6.
5. Alsafwah S, Lababidi Z. Recurrent pulmonary embolism originating from right atrial myxoma. J Am Soc Echocardiogr. 2001;14:305–7.
6. Bilku RS, Loubani M, Been M, Patel RL. Massive right atrial myxoma causing exertional dyspnoea. Eur J Echocardiogr. 2008; 9:130–2.
7. Surabhi SK, Fasseas P, Vandecker WA, Hanau CA, Wolf NM. Right atrial myxoma in a patient presenting with syncope. Tex Heart Inst J. 2001;28:228–9.
8. Uner A, Dogan M, Sal E, Peker E. Stroke and recurrent peripheral embolism in left atrial myxoma. Acta Cardiol 2010 Feb; 65 (1):101-3.
9. Lee VH, Connolly HM, Brown RD Jr. Central nervous system manifestation of cardiac myxoma. Arch Neurol. 2007 Aug; 64(8):1115-20.
10. Kanda T, Takahashi T. Interleukin-6 and cardiac myxoma. Am J Cardiol. 1994;74:965–7.
11. Bertherat J. Carney complex (CNC). Orphanet J Rare Dis. 2006 Jun 6;1:21.
12. Neragi-Miandoab S, Kim J, Vlahakes GJ. Malignat tumors of the heart: a review of tumor type, diagnosis and therapy. Clin Oncol (R Coll Radiol) 2007 Dec; 19(10):748-56

Source(s) of Funding


Clinical history of a patient admitted to emergency room

Competing Interests


This paper is not been published elsewhere and is not currently under consideration by another journal or any other publisher. All the authors approved the article’s publication. No conflicts of interest exists in this submitted manuscript by the authors.

 

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