574 Giant left atrial myxoma in ischaemic stroke

Aims Primary cardiac tumours are rare; most are benign, and of these, around half are myxomas, often located in the left atrium. Clinical presentation is variable. Ischaemic stroke is a rare, although real and potentially fatal, complications of cardiac myxomas. Methods and results We present a case of a 51-year-old man, ex- smoker, obese, with a history of hypertension and COPD, presented to our emergency department with right-sided hemiplegia and aphasia caused by ischaemic stroke. Brain computed tomography revealed cerebral perfusion deficit. The patient was underwent intravenous thrombolytic strategy and intubated transferred in Reanimation. TTE showed a large left atrial mass attached to the interatrial septum, with a friable appearance, suggestive of myxoma. The 2D and 3D TEE detected a giant space-occupying mass (60 × 20 mm diameter) in the left atrium, coral-like, and with a friable appearance, the most apical portion prolapsed into the left ventricle during diastole, causing fixed obstruction to flow in the left ventricular inflow tract. Computed tomography angiography (CTA) confirmed the giant mass in the left atrium. In view of the risk of imminent embolization, the emergent surgical excision of the tumour was performed. The tumour and its neck, including part of the atrial septum, were fully resected and the atrial septum was directly closed. Subsequent histopathological findings confirmed the diagnosis of atrial myxoma. Post-operative echocardiography showed no residual tumour. Symptomatic cardiac myxoma may present with one of the three classic clinical presentations of the Goodwin’s triad, which include intracardiac obstruction, constitutional symptoms, and embolism. The obstructive pattern mimics mitral or tricuspid valve disease and results from atrioventricular valve obstruction. Constitutional or systemic manifestations include fatigue, fever, weight loss, arthralgia, myalgia, erythematous rash, and laboratory findings such as anaemia and elevated ESR, CRP, and globulins. Systemic embolization from myxoma occurs in around a third of cases. Of these, the most serious is cerebrovascular embolism, which may result in cerebral stroke. In addition, embolization of coronary arteries, kidneys, intestines, and extremities can also occur. The tumour size, location, and macroscopic appearance, along with mean platelet volume and platelet count, are closely associated with embolic events. Echocardiography remains the method of choice for diagnosis and morphological characterization of myxoma. Two patterns have been established by echocardiography: round, with a solid appearance and a firm surface, and polypoid, with an irregular outline and a friable surface. The incidence of systemic embolization is higher in those with an irregular and friable surface, as well as in polypoid tumours and those that prolapse into the ventricle. Once a diagnosis of myxoma is established, surgical resection is the only effective treatment and should be performed immediately, in view of the risk of embolic complications. Conclusions With this case report, we stress the fundamental importance of echocardiography in new onset of neurological deficit to prevent potentially fatal outcomes.

Intraosseous fluid resuscitation causes systemic fat emboli in a porcine hemorrhagic shock model

Background Intraosseous cannulation can be life-saving when intravenous access cannot be readily achieved. However, it has been shown that the procedure may cause fat emboli to the lungs and brain. Fat embolization may cause serious respiratory failure and fat embolism syndrome. We investigated whether intraosseous fluid resuscitation in pigs in hemorrhagic shock caused pulmonary or systemic embolization to the heart, brain, or kidneys and if this was enhanced by open chest conditions. Methods We induced hemorrhagic shock in anesthetized pigs followed by fluid-resuscitation through bilaterally placed tibial (hind leg) intraosseous cannulas. The fluid-resuscitation was limited to intraosseous or i.v. fluid therapy, and did not involve cardiopulmonary resuscitation or other interventions. A subgroup underwent median sternotomy with pericardiectomy and pleurotomy before hemorrhagic shock was induced. We used invasive hemodynamic and respiratory monitoring including Swan Ganz pulmonary artery catheter and transesophageal echocardiography and obtained biopsies from the lungs, heart, brain, and left kidney postmortem. Results All pigs exposed to intraosseous infusion had pulmonary fat emboli in postmortem biopsies. Additionally, seven of twenty-one pigs had coronary fat emboli. None of the pigs with open chest had fat emboli in postmortem lung, heart, or kidney biopsies. During intraosseous fluid-resuscitation, three pigs developed significant ST-elevations on ECG; all of these animals had coronary fat emboli on postmortem biopsies. Conclusions Systemic fat embolism occurred in the form of coronary fat emboli in a third of the animals who underwent intraosseous fluid resuscitation. Open chest conditions did not increase the incidence of systemic fat embolization.

Aneurysm of Left Atrial Appendage: Report of two repaired cases

Left atrial appendage aneurysm is a rare heart defect; Most often diagnosed incidentally but may be potentially hazardous when presented with a systemic embolization or arrhythmia. So early diagnosis and treatment is indicated. We have successfully operated two cases of left atrial aneurysm in recent past and sharing our experiences through this case reports. Bangladesh Heart Journal 2021; 36(2): 158-163

Intraosseous Fluid Resuscitation Causes Systemic Fat Emboli in a Porcine Hemorrhagic Shock Model

BackgroundIntraosseous cannulation can be life-saving when intravenous access cannot be readily achieved. However, it has been shown that the procedure may cause fat emboli to the lungs and brain. Fat embolization may cause serious respiratory failure and fat embolism syndrome. We investigated whether intraosseous fluid resuscitation in pigs in hemorrhagic shock caused pulmonary or systemic embolization to the heart, brain, or kidneys and if this was enhanced by open chest conditions.MethodsWe induced hemorrhagic shock in anesthetized pigs followed by fluid-resuscitation through bilaterally placed tibial intraosseous cannulas. A subgroup underwent median sternotomy with pericardiectomy and pleurotomy before hemorrhagic shock was induced. We used invasive hemodynamic and respiratory monitoring including Swan Ganz pulmonary artery catheter and transesophageal echocardiography and obtained biopsies from the lungs, heart, brain, and left kidney postmortem.ResultsAll pigs exposed to intraosseous infusion had pulmonary fat emboli in postmortem biopsies. Additionally, seven of twenty-one pigs had coronary fat emboli. None of the pigs with open chest had fat emboli in postmortem lung, heart, or kidney biopsies. During fluid-resuscitation, three pigs developed significant ST-elevations on ECG; all of these animals had coronary fat emboli on postmortem biopsies. ConclusionsSystemic fat embolism occurred in the form of coronary fat emboli in a third of the animals who underwent intraosseous fluid resuscitation. Open chest conditions did not increase the incidence of systemic fat embolization.

Clinical Features, Echocardiographic Findings, Management and Outcome in a Young Male Patient with Atrial Myxoma: A Rare Primary Cardiac Tumor

Primary cardiac tumors in pediatric are rare and mostly benign. Atrial Myxoma is the most common primary tumor of the heart, which is usually involved in the left atrium. Surgical treatment is recommended when the patients develop symptoms or hemodynamically is impaired. Cardiac Myxoma can cause left atrial obstruction and systemic embolization. So early diagnosis with surgical intervention is the definitive management of the tumor and should not be delayed. Here we present a case of a 23-year old male who admitted to the emergency department with syncope and dyspnea for 1day ago. The tumor was removed surgically; pathologic examination confirmed the diagnosis of Myxoma.

Big Mitral Annular Calcification (Big MAC) – A case report of a dynamic liquefaction necrosis as a potential source of embolism

Background Mitral annular calcification (MAC) is a degenerative, mostly asymptomatic abnormality in usually elderly patients. Caseous MAC (cMAC) is a rare form with central liquefaction necrosis, which typically involves the posterior annulus of the mitral valve and can cause serious sequelae. However, optimal management of patients with cMAC is not clearly defined. Case Summary In a 71-year-old female patient, MAC was incidentally detected. Tissue characterization with cardiac magnetic resonance (CMR) revealed a cMAC and a conservative approach was chosen. Six months after cMAC diagnosis the patient developed an acute hemi-occlusion of a retinal artery with cholesterol embolism. At this time, CMR showed a liquefied cavity of the cMAC. Except for atherosclerotic plaques in the aorta and carotid arteries, further stroke work-up was negative. Therefore, the conservative approach was continued. During follow-up, the liquefied cavity regressed completely after another 6 months and the patient was free from further events (total follow-up 3 years since diagnosis of cMAC). Discussion A clear diagnosis and quantitative assessment of dynamic processes such as cMAC are made possible by performing CMR with multi-parametric tissue characterization. Dynamic changes in cMAC may have serious clinical implications such as mitral regurgitation or systemic embolization. Among cardiac tumours, thrombus and abscess, cMAC should be included in the differential diagnosis of an intracardiac mass of the posterior mitral annulus in order to avoid further inappropriate diagnostic interventions.

An Interesting Case of Acute Stroke: When Many Things Went Wrong, but the Patient Laughed at Last!

A 52-year-old lady with hypertrophic obstructive cardiomyopathy, atrial flutter, and old right hemispheric stroke in the background underwent implantable cardioverter-defibrillator implantation for complete heart block. She was yet to start her regular anticoagulant and presented to hospital emergency with acute right middle cerebral artery (MCA) territory stroke (NIH Stroke Scale/Score of 14). After ruling out absolute contraindications, she was given intravenous thrombolysis (did not have a blood vessel target for endovascular therapy). Post thrombolysis, she had clot mobilization from the internal carotid artery to the MCA and systemic embolization to kidneys and lower limbs. The patient underwent an urgent embolectomy and lower limbs were saved from amputation. Our case highlights the importance of checking peripheral pulses in acute stroke patients post thrombolysis. Though the patient had initial deterioration after thrombolysis, she gradually improved and later achieved satisfactory modified Rankin scale underscoring the ultimate potential benefits of thrombolysis in acute stroke. There is a high chance of thrombus formation in patients with atrial flutter who undergo recent cardiac procedure especially if they are off anticoagulation for even a short period. Hence, unnecessary apprehension of anticoagulant use in proper situations may create life-threatening complications.

Patent Foramen Ovale and Cryptogenic Stroke: Challenges in Diagnosis and Management

A patent foramen ovale (PFO) is a common disorder that affects between 20-34% of the adult population. This condition is a benign finding for most people. However, In some the PFO can open widely and enabling paradoxical embolism to transit from venous to arterial circulation, which is associated with stroke and systemic embolization. There are still unclear to date regarding the effectiveness of pharmacological anticoagulant therapy, defined as antithrombin or antiplatelet therapy, which has proven to be more beneficial for patients with PFO and cryptogenic stroke. In addition, surgical and transcutaneous PFO closure has been proposed for secondary prevention of stroke in patients with cryptogenic stroke with PFO. Both catheter-based and surgical modes of closure have been shown to reduce the incidence of subsequent embolism substantially. This review will discuss the evidence regarding the relationship between PFO and cryptogenic stroke and decision making for management strategies.

ST-segment elevation myocardial infarction due to septic coronary embolism: a case report

Background Coronary artery embolism is an infrequent cause of type 2 myocardial infarction which can be due to arterial thromboembolism or septic embolism. While systemic embolization is one of the most acknowledged and threatened complications of infective endocarditis, coronary localization of the emboli causing acute myocardial infarction is exceedingly rare occurring in less than 1% of cases. Case summary A 52-year-old man with a history of Bentall procedure and redo aortic valve replacement due to prosthetic degeneration (eleven years prior the current presentation) presented to the emergency department with high-grade fever and myalgias. Shortly after his arrival he experienced typical chest pain and an ECG demonstrated signs of inferior ST-elevation myocardial infarction: coronary angiography showed a lesion of presumed embolic origin at the level of the mid-distal circumflex coronary artery which was treated with embolectomy. Transthoracic and transesophageal echocardiography highlighted the presence of a periaortic abscess. The final diagnosis of infective endocarditis as the cause of septic coronary artery embolization was confirmed with a PET-CT exam and by the growth of Staphylococcus Lugdunensis on repeated blood cultures. The patient underwent successful redo Bentall surgery the good outcome was confirmed at 1-month follow-up. Discussion Type 2 myocardial infarction caused by coronary embolism is a rare presentation of infective endocarditis and requires a high level of suspicion for its diagnosis. Prosthetic heart valves are a predisposing factor for infective endocarditis: aortic root abscess requires surgery as it rarely regresses with antibiotic therapy.