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      Concomitant Left Atrial Myxoma and Patent Foramen Ovale: Is It an Evolutional Synergy for a Cerebrovascular Event?

      case-report

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          Abstract

          We report a case of a 48-year-old female who presented initially with an abrupt onset of left facial and hand numbness after her routine yoga with no associated syncope, palpitation, chest pain or dyspnea. She consulted her primary care physician and recommended hospital care for possible stroke. On the day of admission, she complained of left facial and hand hemiparesthesia. Cranial imaging and angiography were unremarkable but echocardiography and cardiac computed tomography revealed left atrial mass. She underwent resection of the left atrial mass with an incidental finding of patent foramen ovale intraoperatively. The left atrial mass was confirmed to be an atrial myxoma. Patient’s neurologic complaints resolved towards the end of her hospital course. She was discharged stable with no recurrence of neurologic symptoms on health maintenance evaluation.

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          Cardiac myxomas.

          K Reynen (1995)
          Although cardiac myxomas are histologically benign, they may be lethal because of their strategic position. They can mimic not only every cardiac disease but also infective, immunologic, and malignant processes. Myxomas must therefore be included in the differential diagnosis of valvular heart disease, cardiac insufficiency, cardiomegaly, bacterial endocarditis, disturbances of ventricular and supraventricular rhythm, syncope, and systemic or pulmonary embolism. The symptoms depend on the size, mobility, and location of the tumor. Echocardiography, including the transesophageal approach, is the most important means of diagnosis; CT and MRI may also be helpful. Coronary arteriography in patients over 40 years of age is generally required to rule out concomitant coronary artery disease. Surgical removal of the tumor should be performed as soon as possible; the long-term prognosis is excellent, and recurrences are rare. In follow-up examinations as well, echocardiography is essential.
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            Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases.

            P Duhaut, L Pinede, R Loire (2001)
            We analyzed a series of 112 consecutive cases of left atrial myxoma diagnosed in a single French hospital (72 women and 40 men; age range, 5-84 yr) over 40 years, from 1959 to 1998. Symptoms of mitral valve obstruction, the first arm of the classic triad of myxoma presentation, were present in 75 patients (67%), with mostly cardiac failure or malaise. Symptoms of embolism, the second frequent presentation in the classic triad, were observed in 33 cases (29%) with 1 or several locations, essentially cerebral emboli with stroke. Males are statistically at greater risk than females of developing embolic complications. The third arm of the classic triad consists of constitutional symptoms (34%) with fever, weight loss, or symptoms resembling connective tissue disease, due to cytokine (interleukin-6) secretion. Younger and male patients have more neurologic symptoms, and female patients have more systemic symptoms. Seventy-two patients (64%) had cardiac auscultation abnormalities, essentially pseudo-mitral valve disease (53.5%) and more rarely the suggestive tumor plop (15%). The most frequent electrocardiographic sign was left atrial hypertrophy (35%), whereas arrhythmias were uncommon. The greater number of myxoma patients (98) diagnosed preoperatively after 1977 reflects the introduction of echocardiography as a noninvasive diagnostic procedure. However, there was no significant reduction in the average time from onset of symptoms to operation between patients seen in the periods before and after 1977. The tumor diameter ranged from 1 to 15 cm with a weight of between 15 and 180 g (mean, 37 g). The myxoma surface was friable or villous in 35% of the cases, and smooth in the other 65% cases. Myxomas in patients presenting with embolism have a friable surface; those in patients with cardiac symptoms, pseudo-mitral auscultation signs, tumor plop, and electrocardiogram or radiologic signs of left atrium hypertrophy and dilatation are significantly the larger tumors. The long-term prognosis is excellent, and only 4 deaths occurred among our 112 cases over a median follow-up of 3 years. The recurrence rate is low (5%), but long-term follow-up and serial echocardiography are advisable especially for young patients.
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              Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies.

              K Y Lam, P Dickens, A Chan (1993)
              Cardiac involvement by primary and secondary tumors is one of the least investigated subjects in oncology. Seven cases of primary and 154 cases of secondary cardiac tumors from autopsies performed over a 20-year period (1972 through 1991) at Queen Mary Hospital, Hong Kong, were reviewed. During this period, 12,485 autopsies were performed, and the autopsy incidence for primary and secondary heart tumors is thus 0.056% and 1.23%, respectively. Only seven primary cardiac tumors were found, including two myxomas, two rhabdomyomas, two hemangiomas, and one lipoma. For secondary tumors involving the heart (including both metastasis and local extension), important primary tumors in male subjects were carcinoma of the lung (31.7%), esophageal carcinoma (28.7%), lymphoma (11.9%), carcinoma of the liver (6.9%), leukemia (4.0%), and gastric carcinoma (4.0%), while in female subjects, carcinoma of the lung (35.9%), lymphoma (17.0%), carcinoma of the breast (7.5%), and pancreatic carcinoma (7.5%) predominated. Overall, the three most common malignant neoplasms encountered were carcinoma of the lung, esophageal carcinoma, and lymphoma. Pericardium, including epicardium, was the most common location of cardiac involvement by secondary tumors, followed by myocardium and endocardium. The present study showed a higher percentage of esophageal carcinoma and carcinoma of the liver (reflecting the higher incidence of these tumors in Hong Kong Chinese), but a lower incidence of carcinoma of the breast when compared with other series. The metastatic lung tumors showed an unusual predominance of adenocarcinoma.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cardiol Res
                Journal ID (iso-abbrev): Cardiol Res
                Journal ID (publisher-id): Elmer Press
                Title: Cardiology Research
                Publisher: Elmer Press
                ISSN (Print): 1923-2829
                ISSN (Electronic): 1923-2837
                Publication date (Print): February 2017
                Publication date (Electronic): 03 March 2017
                Volume: 8
                Issue: 1
                Pages: 26-29
                Affiliations
                [a ]Department of Medicine, Atlantic Health System-Overlook Medical Center, Summit, NJ 07901, USA
                Author notes
                [b ]Corresponding Author: Glenmore Lasam, Department of Medicine, Overlook Medical Center, 99 Beauvoir Avenue, Summit, NJ 07901, USA. Email: glenmore_md@ 123456yahoo.com
                Article
                DOI: 10.14740/cr522w
                PMC ID: 5340522
                SO-VID: 00761648-2dba-41b3-9bc0-ece59c43a3aa
                Copyright © Copyright 2017, Lasam et al.
                License:

                TThis article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date accepted : 06 February 2017
                Categories
                Subject: Case Report

                Keywords: left atrial myxoma,patent foramen ovale,cerebrovascular event,cardioembolic stroke,cryptogenic stroke,paradoxical embolism
                Data availability:
                Keywords: left atrial myxoma, patent foramen ovale, cerebrovascular event, cardioembolic stroke, cryptogenic stroke, paradoxical embolism

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