Özet

This report describes the case of a 55-year-old woman with a huge left atrial myxoma prolapsing into the left ventricular cavity through the mitral valve. Only a thin path allowed blood flow through the left atrial chamber to the left ventricle. Despite this obstruction, the patient developed only minimal symptoms. The giant mass was successfully removed and the patient is doing well one year after surgery without recurrence.

Myxomas are the most common primary cardiac tumors. They are usually benign and have variable presentations. Although rare, atrial myxomas are the most important cardiac tumors to diagnose, as they have an excellent prognosis following surgical excision [1]. Eighty to eighty-five per cent of the reported myxomas are originated from left atrium [1-3]. We report a case of unusually large left atrial myxoma with only minimal symptoms.

A 55-year-old woman was admitted to the hospital with a history of exertional palpitation of two weeks duration with no previous cardiac symptoms. History was not positive for rheumatic fever, collagen diseases, malignancy, irradiation, renal failure, metabolic disorders or chest trauma. On examination, the blood pressure was 110/70 mmHg with a regular pulse of 92/min and a respiratory rate of 22/min. No third heart sounds was heard. No rubs but an apical 1-2/6 pansystolic murmur was audible. There was no other pathological finding. A chest X-ray was in normal limit but the heart was mildly enlarged. The electrocardiography revealed sinus rhythm and left ventricular enlargement. Echocardiography findings were consistent with a huge left atrial mass originated from interatrial septum and prolapsing into the left ventricular cavity through the mitral valve and causing severe mitral stenosis. Almost the half of the left ventricular cavity was occupied by the mass. The left atrial mass were measured 96x38 cm (Figure 1). Left heart catheterization and coronary angiography were performed. Coronary arteries and systolic left ventricular function were normal.

Figure 1. Echocardiografic appearance of the huge myxoma occupying almost entire left atrial and ventricular cavities.

The patient was taken to operation. A midline sternotomy was performed. The ascending aorta and the bicaval cannulation were completed. Cardiopulmonary bypass was established. The left atrium was opened. A huge left atrial mass originated from interatrial septum and occupying almost the entire left atrial cavity was seen. The right atrium then was opened and interatrial septum was incised around the fossa ovalis where the mass was originated and the mass was taken out through left atrial incision. The yellowish gelatinous mass was measured 120x50x30 mm. No remaining mass was inspected in left and right heart chambers. Mitral valve was inspected and appeared normal. All four cardiac chambers were explored for multiple tumor or fragments of the myxoma. The mass weighted 172 g. Microscopic examination of the mass revealed benign myxoma. The postoperative course was uneventful and the patient was discharged at the fifth postoperative day. The patient is doing well one year after surgery without recurrence.

Tartışma

Myxomas are the most common primary cardiac tumors. They are usually benign and have variable presentations. Clinical presentations varied from no symptoms and mild clinical signs to various presentations. Jelic and assosiates [2] has reported 8.6% symptomless patients in their 81 patiens series. The common symptoms include congestive heart failure, peripheral embolization and syncopal episodes, however cardiac myxoma may mimic many cardiovascular diseases, so a high index of suspicion is important for its diagnosis [2,4,5]. Additionally constitutional symptoms such as fever and weight loss may accompany. Echocardiography is the most useful diagnostic screening tool. The natural history of atrial myxoma is not well establised. However, without surgical treatment, the medium and long-term prognosis is considered fatal. Therefore once the cardiac myxoma is identified by two-dimensional echocardiography, the tumor should be removed even in patients without symptoms. Surgical resection of a single myxoma is a safe and effective treatment, with a low risk of recurrence [1-3]. The case reported here is atypical in that the patient developed only minimal symptoms despite only a thin path allowed blood flow through the left ventricle due to the large size of the myxoma. In currently available English literature, giant cardiac myxomas size up to 18x7x5 cm [6] and weight up to 180 gram [7] have been reported, however to our knowledge, atrial myxoma in that size without significant symptoms has not been published.

Kaynaklar

1) Keçecigil HT, Demir Z, Kolbakır F, Demirağ MK, Akar H. Kardiyak miksoma ve cerrahi tedavisi. Türk Göğüs Kalp Damar Cer Derg 1999;7:210-6.

2) Jelic J, Milicic D, Alfirevic I, et al. Cardiac myxoma: Diagnostic approach, surgical treatment and follow-up. A twenty years experience. J Cardiovasc Surg 1996;37:113-7.

3) Castells E, Ferran V, Octavio de Toledo MC, et al. Cardiac myxomas: Surgical treatment, long-term results and recurrence. J Cardiovasc Surg 1993;34:49-53.

4) Bjessmo S, Ivert T. Cardiac myxoma: 40 year’s experience in 63 patient. Ann Thorac Surg 1997;63:697-700.

5) Meyns B, Vancleemput J, Flameng W, Daenen W. Surgery for cardiac myxoma. A 20-year experience with long-term follow-up. Eur J Cardiothorac Surg 1993;7:437-40.

6) Durgut K, Görmüş N, Özülkü M, et al. Clinical features and surgical treatment of cardiac myxoma: Report of 18 cases. Asian Cardiovasc Thorac Ann 2002;10:111-4.

7) Pinede L, Duhaut P, Loire R. Clinical presentations of left atrial cardiac myxoma. A series of 112 concecutive cases. Medicine 2001;80:159-72.