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      Hemodynamic management of a patient with a huge right atrium myxoma during thoracic vertebral surgery : A case report

      case-report
      , MM, , MM, , MM, , MD
      Medicine
      Wolters Kluwer Health
      hemodynamic change, myxoma, prone position, right atrium

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          Abstract

          Rationale:

          Myxoma is the most common primary benign cardiac tumor, which could lead to some fatal complications because of its strategic position.

          Patient concerns:

          The patient was admitted to our hospital due to sudden onset of palpitation, chest tightness, mild fever, night sweats, accompanied with bilateral lower extremities adynamia, and paralysis for 5 days, but no obvious syncope and edema.

          Diagnoses:

          Transthoracic echocardiography showed a giant mobile myxoma (72 × 58 mm) in the right atrium (RA). Magnetic resonance imaging revealed an erosive space-occupying lesion located between the first and third thoracic vertebrae.

          Interventions:

          Thoracic vertebral lesions were resected immediately to rescue the incomplete paraplegia. After the patient was placed in the prone position, significant hemodynamics changes were observed due to the displacement of the huge RA myxoma.

          Outcomes:

          Stable hemodynamics was maintained during the operation through control of fluid infusion combined with vasoactive drugs.

          Lessons:

          Change in body position may lead to obstruction of intracardiac blood flow in patients with giant myxoma. This clinical manifestation is rarely reported.

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          Most cited references20

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          Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases.

          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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            Primary cardiac tumors.

            Cardiac tumors are a rare, but potentially curably form of heart disease. A high index of clinical suspicion is necessary for diagnosis as these tumors have protean manifestations that mimic a variety of other cardiac and noncardiac diseases. Presently, M-mode and two-dimensional echocardiography are utilized as safe, reliable, and noninvasive imaging modalities. Seventy-five per cent of these tumors are benign, with myxoma accounting for 50% and rhabodomyoma comprising 20% of lesions. Various histologic types of sarcoma are the predominant malignant cardiac neoplasms. With strict attention to avoiding perioperative tumor embolization, surgical resection of these lesions can be accomplished with minimal morbidity and mortality. Sixteen consecutive primary tumors of the heart have been surgically treated at Duke University Medical Center since 1966 with no perioperative deaths and no late recurrences.
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              Primary cardiac tumors: experience at the University of Minnesota.

              A review of all primary cardiac tumors seen at the University of Minnesota or entered in the Registry of Cardiovascular Disease, affiliated with the University of Minnesota, between 1959 and 1989. Of a total of 124 primary cardiac tumors, 103 (83%) were benign and 21 (17%) were malignant. Atrial myxomas (51 cases) accounted for 42% of all tumors and 50% of benign neoplasias. The remaining 51 benign tumors were, in order of frequency: rhabdomyomas, 14 (13%), papillomas, 12 (11%), fibromas, 9 (9%), hamartomas, (4%), teratomas (2%), lipomas (2%), mesotheliomas (2%), fibroelastomas, hemangiomas, glomangiomas, and a few others. The 21 malignant tumors, all sarcomas, were, in order of frequency: rhabdomyosarcomas, 6 (29%), angiosarcomas, 4 (19%), myxosarcomas, 3 (14%), fibrosarcomas, 2 (10%), and one each leiomyosarcoma, reticulum cell sarcoma, and liposarcoma. There were 3 cases of spindle cell sarcoma (14%) originating in the great vessels: 1 in the pulmonary artery and 2 in the aorta. The prognosis of the resected benign tumors was good, with no complications of recurrences for up to 15 years of follow-up. Tumors that could not be excised included mostly rhabdomyomas, in newborns, and cavernous hemangiomas involving most of the heart, with poor prognosis. Malignant tumors of the heart had a very poor prognosis, even when operated on promptly after diagnosis. The mean survival time of these patients was 5 months after resection, even when followed with chemotherapy and/or radiation; 26% of the tumors had already metastasized at the time of operation. Extensive resections in malignant tumors did not render satisfactory results.
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                Author and article information

                Journal
                Medicine (Baltimore)
                Medicine (Baltimore)
                MEDI
                Medicine
                Wolters Kluwer Health
                0025-7974
                1536-5964
                September 2018
                28 September 2018
                : 97
                : 39
                : e12543
                Affiliations
                Department of Anesthesiology, Lanzhou University Second Hospital, Lanzhou, China.
                Author notes
                []Correspondence: Yingbin Wang, Department of Anesthesiology, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030, China (e-mail: wangyingbin6@ 123456163.com ).
                Article
                MD-D-18-02576 12543
                10.1097/MD.0000000000012543
                6181536
                30278547
                32a909a6-4008-4d90-ad7e-6bd13934470e
                Copyright © 2018 the Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

                History
                : 28 April 2018
                : 3 September 2018
                Categories
                3300
                Research Article
                Clinical Case Report
                Custom metadata
                TRUE

                hemodynamic change,myxoma,prone position,right atrium
                hemodynamic change, myxoma, prone position, right atrium

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