Abstract
Primary cardiac tumors are very rare causes of intracavitary masses, about 5% of all cardiac tumors. Most of them are benign tumors, and 50% are represented by atrial myxomas. They are usually developed in the left atrium, with a pedicle attached to the interatrial septum. Cardiac myxomas are one of the "greatest mimes" of pathology, with a polymorphic clinical presentation, from obstructive, to embolic and constitutional clinical manifestation.
We present the case of a 58-year-old female patient with 4 years history of chronic obstructive pulmonary disease (COPD), on bronchodilator treatment and long-term oxygen therapy. She accused two months duration of abdominal distension due to ascites, for which she was evaluated in the gastroenterology department and received diuretics association. The symptoms were refractory to the treatment, so the patient was referred for cardiovascular examination.
At presentation, the patient was afebrile, with a heart rate of 100/minute, blood pressure was 125/90 mmHg. Cardiovascular examination did not reveal any murmurs, jugular venous distension was present. 12-lead electrocardiogram (ECG): sinus rhythm, with right atrial enlargement. The transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) revealed a lobulated giant mass in RA, which occupied almost the entire cavity, with prolapse towards the right ventricle during diastole. Due to the large intracavitary mass, the point of attachment could not be ascertained. Computed tomography (CT) of the thorax was performed and it confirmed the presence of the giant right cardiac mass.
The patient underwent surgical excision of the tumor under cardiopulmonary bypass. Intraoperative findings were represented by a yellowish-brown lobulated friable mass in the right atrium cavity, measuring 70/30/35 mm. The pedicle of the tumor was inserted on the free wall of the right atrium. The histopathological examination revealed round to stellate cells in a myxoid stroma, specific for cardiac myxoma. Postoperative evolution was influenced by the severe pulmonary disease, with prolonged mechanical ventilation and positive inotropic support, but it was slowly favorable, and the patient was discharged in good condition.
Right atrial myxoma is a very rare intracardiac tumor with nonspecific forms of clinical presentations, that create difficulties in diagnosis. Ascites represents an unusual form of manifestation in a patient with a cardiac tumor. The insertion of the pedicle of the myxoma was atypical and induced difficulties in early evaluation of the tumor type. Even though myxomas are mainly benign tumors, the complication rate is very high, especially of embolic events due to the friable tumoral mass, so they can become life threatening conditions. Early diagnosis of cardiac myxoma based on multimodality imaging is essential, leading to optimal surgical management, with good long-term survival.
Abstract P854 Figure. TEE view of giant RA tumor
Right atrial epithelioid angiosarcoma with multiple pulmonary metastasis confirmed by multimodality imaging-guided pulmonary biopsy