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CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 4  |  Page : 139-142

A rare cause of paroxysmal atrial fibrillation: Mass in the left atrium


1 Department of Cardiology, Sree Uthram Thirunal Royal Hospital, Thiruvananthapuram, Kerala, India
2 Department of Cardiology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India

Date of Web Publication20-Dec-2016

Correspondence Address:
Biji Soman
Department of Cardiology, Sree Uthram Thirunal Royal Hospital, Ulloor, Medical College (PO), Thiruvananthapuram - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-449x.196280

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  Abstract 

A 57-year-old female with no known comorbidities presented to us with complaints of exertional dyspnea New York Heart Association Class II and occasional gray out. Clinical examination was unremarkable. Outpatient 12-lead electrocardiogram showed atrial fibrillation (AF) with fast ventricular rate. Transthoracic echocardiogram revealed a mass in the left atrium. The patient was advised to undergo surgical excision of the mass. The patient underwent the surgery. Her rhythm reverted back to sinus rhythm. Histopathology revealed the mass to be petrified cardiac myxoma. This case is unique because patients with atrial myxoma presenting with AF are rare, and petrified cardiac myxoma is a rare histological variety.

Keywords: Paroxysmal atrial fibrillation, petrified cardiac myxoma, transthoracic echocardiography


How to cite this article:
Soman B, Rahaman MA. A rare cause of paroxysmal atrial fibrillation: Mass in the left atrium. Heart India 2016;4:139-42

How to cite this URL:
Soman B, Rahaman MA. A rare cause of paroxysmal atrial fibrillation: Mass in the left atrium. Heart India [serial online] 2016 [cited 2021 Dec 2];4:139-42. Available from: https://www.heartindia.net/text.asp?2016/4/4/139/196280


  Introduction Top


Primary cardiac tumor is extremely rare. Myxoma is the most common intracardiac tumor, 80% of these tumors are located in the left atrium and mainly originate from an area in the atrial septum near the fossa ovalis.[1],[2] Nearly 75% of cardiac tumors are benign and often asymptomatic. However, occasionally, they can lead to embolization, conduction disturbances, and valve obstructions.[3]

We present a case of a 57-year-old female, who presented with the complaints of exertional dyspnea New York Heart Association (NYHA) Class II and paroxysmal atrial fibrillation (AF).


  Case Report Top


A 57-year-old female, with no known comorbidities, presented with complaints of exertional dyspnea NYHA Class II and occasional gray outs. She did not have any significant past medical history. On clinical examination, her pulse rate was found to be fast and irregular and she was hemodynamically stable. Systemic examination was unremarkable. Outpatient 12-lead electrocardiogram revealed AF with fast ventricular rate [Figure 1]. Her thyroid function was normal, and other routine laboratory results were within normal limits. The patient was treated with amiodarone to control the ventricular rate.
Figure1: Preoperative 12-lead electrocardiogram showing atrial fibrillation

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Two-dimensional transthoracic echocardiography (TTE) was done to ascertain the cause of exertional dyspnea and AF. TTE revealed borderline left ventricular hypertrophy with good biventricular systolic function. All valves appeared structurally normal. A large mass was seen in the left atrium measuring 5.2 cm × 3.7 cm, which was pedunculated with the stalk attached to the interatrial septum [Figure 2]. The mass was protruding into the left ventricle during diastole [Figure 3], and there was no significant mitral regurgitation during systole. The mitral valve cusps were freely moving [Figure 4].
Figure2: Transthoracic echocardiogram in apical 4-chamber view showing a large mass in the left atrium measuring 5.2cm×3.7cm

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Figure3: Transthoracic echocardiogram in apical 4-chamber view showing the left atrial mass protruding into the left ventricle during diastole

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Figure4: Transthoracic echocardiogram in apical 3-chamber view showing the free mitral leaflets

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The patient was advised surgical removal of the mass. She underwent the excision of the left atrial mass under general anesthesia. Intraoperative period was uneventful. Her rhythm reverted back to sinus rhythm in the postoperative period [Figure 5]. The histopathology report came as petrified atrial myxoma. The patient did well in the postoperative period and was discharged in a clinically and hemodynamically stable state with advice to follow-up at regular intervals in our outpatient clinic.
Figure5: Postoperative 12-lead electrocardiogram showing normal sinus rhythm

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  Discussion Top


Left atrial myxoma commonly occur between the age of 30 and 60 years, most commonly seen in women and are solitary and pedunculated, 90% occur as sporadic cases and 10% being familial, with an autosomal dominant pattern of inheritance.[4] In 5% of cases, myxomas can be multiple. Other locations are right atrium (next most common), ventricles, superior vena cava, or pulmonary veins.[5]

Differential diagnosis of atrial myxoma includes pedunculated thrombus, metastatic sarcoma, and melanoma in the left atrium.[6] Other metastatic tumors could specifically metastasize through inferior vena cava to the right side of the heart and include hypernephroma, hepatoma, melanoma, and intravenous leiomyomatosis from uterus.[5]

Early diagnosis of intracardiac tumors is difficult because they often present with nonspecific symptoms.[7] Symptoms are often due to flow obstruction or peripheral embolization. It may be intermittent, owing to occasional prolapse of pedunculated mobile tumors through the atrioventricular valves.[8] They may also present with dyspnea, arrhythmias, precordial uneasiness, dizziness and syncopal episodes, heart failure, and acute pulmonary edema due to valve obstruction. Patients with myxoma may also present with Raynaud phenomenon, anemia, fever, weight loss, hypergammaglobulinemia, and an increased erythrocyte sedimentation rate due to the interleukin-6 release from the tumor cells.[9]

Surgical excision is the only definitive treatment for atrial myxoma. TTE has less specificity than the transesophageal echocardiography (TEE). Conservative management is of limited value in symptomatic patients with large myxomas. However, in asymptomatic patients and in patients with a slow growing or small tumor or with high operative risk, a conservative strategy with periodic monitoring of tumor with either TTE or TEE and anticoagulation may be prudent.[5]

The diagnosis of atrial myxoma can be difficult, especially when symptoms are suggestive of other diagnoses. In this case, when the patient presented with new symptoms of AF, TTE to look for the cause of AF revealed the left atrial myxoma.

Petrified cardiac myxoma is a rare histologic variant of atrial myxomas. Lie describes it as an degenerative form of myxoma that has been converted to a sclerosiderotic nodule by impregnation of the tumor's stromal connective tissue fibers with iron, calcium, and ceroid pigments, presumably following recurrent hemorrhage in the myxoma over time.[10]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Medicine (Baltimore) 2001;80:159-72.  Back to cited text no. 1
    
2.
Lamparter S, Moosdorf R, Maisch B. Giant left atrial mass in an asymptomatic patient. Heart J 2004;90:e24.  Back to cited text no. 2
    
3.
Vicari RM, Polanco E, Schechtmann N, Santiago JO, Shaurya K, Halstead M, et al. Atrial myxoma presenting with orthostatic hypotension in an 84-year-old Hispanic man: A case report. J Med Case Rep 2009;3:9328.  Back to cited text no. 3
    
4.
Yap WW, Bhattacharya K, Pathi V. Left atrial myxoma in transplanted heart. Heart J 2005;91:e49.  Back to cited text no. 4
    
5.
Biswas A, Thakur AK. An unusual presentation of atrial myxoma in an elderly patient: A case report. Cases J 2008;1:384.  Back to cited text no. 5
    
6.
Thakur AK, Thakur S. Infection and cardiac tumors: Evaluation through Imaging. Medicine Update. Association of Physicians of India 2003;13:575-82.  Back to cited text no. 6
    
7.
Kuon E, Kreplin M, Weiss W, Dahm JB. The challenge presented by right atrial myxoma. Herz 2004;29:702-9.  Back to cited text no. 7
    
8.
Kim BK, Cho JN, Park HJ, Hong SP, Son JY, Lee JB, et al. Reversible pulmonary hypertension in adolescent with left atrial myxoma. J Cardiovasc Ultrasound 2011;19:221-3.  Back to cited text no. 8
    
9.
Guhathakurta S, Riordan JP. Surgical treatment of right atrial myxoma. Tex Heart Inst J 2000;27:61-3.  Back to cited text no. 9
    
10.
Lie JT. Petrified cardiac myxoma masquerading as organized atrial mural thrombus. Arch Pathol Lab Med 1989;113:742-5.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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