Jorge Roman, B.S., Patrick T. Roughneen, M.D.
March 19, 2017
A 52-year-old woman presented to our institution as a transfer from an outside hospital for further workup and higher level of care. On presentation, the patient complained of chest pain and dyspnea on exertion. The chest pain started 1 week prior and was located in the midsternal region with radiation to the neck, jaw, back, and shoulders. The pain was constant and squeezing in character and increased with physical exertion. The dyspnea on exertion began 6 months prior to presentation and had progressively worsened over the past month. In addition, the patient endorsed experiencing episodes of presyncope during the week prior to admission. During these episodes she experienced diaphoresis, dizziness, and lightheadedness. She did not report any episodes of syncope. She denied symptoms of nausea, vomiting, fever, palpitations, and weight loss. Her medical history was significant for insulin-dependent diabetes mellitus, hypertension, hepatitis C virus infection, and two prior myocardial infarctions. She had coronary artery bypass surgery 8 years ago and multiple percutaneous coronary interventions for coronary artery disease, the most recent performed 6 months ago. There was a strong family history of diabetes and coronary heart disease, present in both of her parents as well as in all of her grandparents.
On physical exam, her heart had a regular rate and rhythm without any murmurs or extra heart sounds. Lungs were clear to auscultation and her abdominal exam was normal. No peripheral edema or jugular venous distension was noted. Initial labs revealed a troponin level within the normal range and there was no evidence of ischemic changes on electrocardiography. A CT scan performed at the outside hospital revealed a left atrial mass, and a transthoracic echocardiogram at our institution confirmed the presence of a mass in the left atrium as well as severely depressed left ventricular systolic function. The patient was monitored on cardiac telemetry, which was unremarkable and did not demonstrate any episodes of dysrhythmia. Transesophageal echocardiography was performed to better visualize the mass and the study revealed a mobile mass in the left atrium attached to the interatrial septum via a short stalk (See Figure 1). There was no evidence of valvular obstruction and the ejection fraction was estimated to be 30 to 35 percent. Surgical exploration revealed a round, gelatinous, plum-colored mass in the left atrium attached at the level of the fossa ovalis. The mass was removed from the atrial cavity and the defect was repaired with a soft tissue patch. Gross examination of the specimen revealed a spherical mass 2.4 cm by 1.5 cm by 1.2 cm in diameter (See Figure 2). The specimen was sent to pathology for confirmation of the suspected diagnosis.
The most likely diagnosis is:
1. Paraskevaidis IA, Michalakeas CA, Papadopoulos CH, Anastasiou-Nana M. Cardiac Tumors. ISRN Oncology. 2011;2011:1-5. doi:10.5402/2011/208929.
2. Messina F, Romano P, Crosca S. Atrial myxomas and different clinical presentations. International Journal of Cardiology. 2016;203:1136-1137. doi:10.1016/j.ijcard.2015.08.063.
Authors: Jorge Roman, B.S., is a fourth year medical student at the University of Texas Medical Branch in Galveston, Texas. Patrick T. Roughneen, M.D., is a cardiac surgeon and Associate Professor in the Division of Cardiothoracic Surgery at the University of Texas Medical Branch.
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