Download Atrial Myxoma

A lady with
acute SOB
Sammi Pe
Case Presentation
• 54/F
• Cat II
• BP 129/69mmHg P 128
• Temp 36.9
• SpO2 78% ( 100% O2)
• Triage : SOB since afternoon, cough
with sputum, mild chest discomfort
What will you
do ?
What further history need?
What further Hx
• Good Past Health
• Domestic helper
• SOB since ~2 hrs ago
• Mild cough with yellowish sputum xdays
become blood stained on AED
• No fever
• Chest discomfort today ( tightness)
• Palpitation +ve
More hx from employer
• Mild exertional SOB x several days
• Need resting after her work
• No fever all along
• No Travel hx
• Work in HK x ~17yrs
• No GI upset/ abd pain
• Not on regular medication
• Non-smoker, non-drinker
P/E
• Alert GCS 15/15
• BP 139/78 P 120
• RR 48
• Sit up for breathing
• SpO2 80% on 100% O2
• Recheck Temp 37.2
• H’stix 13.2
P/E
• Chest: AE fair with
bilateral basal crep,
occ wheeze
• Abd soft
• HS dual, no murmur
• No ankle edema
What will you do
next ?
• ABC
• 100% O2 mask
• HB set
• Blood x CBC, L/RFT, Trop I , Clotting
• ECG
• i stat ( arterial)
• CXR
ECG x 2
i stat (arterial, on 100%O2)
• pH
7.398
• pCO2 5.39 kPa
• pO2 5.8 kPa
• BE
0
• HCO3 24.9 mmol/L
• SO2
79%
• Na 141 K 3.5 i Ca 1.21
Hb 14.6
Our Patient
Problem:
Sudden onset SOB
Desaturation even on 100% O2
Type I Resp Failure
What is yr DDx?
Type I Resp Failure
Typically due to V/Q mismatch
PaO2
low (< 60 mmHg(8.0 kPa))
PaCO2 normal or low
PA-aO2 increased
• Parenchymal disease (V/Q mismatch)
• Diseases of vasculature and shunts:
right-to-left shunt, pulmonary
embolism
• interstitial lung diseases: ARDS,
pneumonia, emphysema.
Patient was still
in distress even
on 100% O2
What will you do then?
• Patient was put on CPAP
• Lasix 40mg iv
• BP 110/70
• Clinically improved
• CXR film A/V….
CXR
What is
yr
Diagnosis?
APO ….
? Other drug(s) to be
considered
? Underlying cause
CCU was consulted
Medications…
• Nitrates
– Vasodilation
– Reduced preload
and afterload
– Improved CO
– Rapid effect
– Not prescribed
likely due to BP on
low side
• Diuretics
– Reduced plasma
volume / preload
– Pulmonary
vasodilatation
• ACEI
– Reduced afterload
– Improved CO
Underlying Causes
• ACS
• HT
• Aortic/mitral valve
disease
• Arrhythmias
•
•
•
•
•
VSD
Cardiomyopathy
Acute myocarditis
Pericardial disease
Atrial myxoma
• Echo was
performed…
Our case
What is show in
the
Echocardiogram?
CCU input
• ECHO:
• LA mass ~4cm
• Likely atrial
myxoma
• Trivial MR/AR
• Normal LV size and
EF
Our Patient
APO secondary to large atrial
myxoma
• Transfer to CCU then CTSU for further
Mx.
Progress
• Emergency excision of atrial myxoma
– 6x5cm encapsulated LA tumour attached to inter-atrial
septum.
– Causing obstruction & pul edema
– Bi-atrial exploration + excision of tumour
• Extubated on D1
• Post-op echo: EF 70%
•
no PE
Day 0
Day 2
Day 1
Day 3
Day 4
Day 20
Patient was discharge on D8 and SOPD FU
On Day 20
Good Recovery, Class I II , ET 3-4 FOS
Atrial Myxoma
Background
Most common 1° Heart tumour (40-50%)
90% solitarty and pedunculated
– Multiple tumours occur in 50% of familial case
10% familial ( autosomal dominant)
75-85% occur in LA
~25% RA
Attach to fossa ovalis
Symptomatic ~ 70g
140g
• Myxoma– polypoid, round,
oval in shape
– Smooth / lobulated
surface
– White/ yellow/
brown
– Produce numberus
growth factors and
cytokines e.g.
interleukin-6
Histology
• lipidic cells embedded in a vascular
myxoid stroma
• In a series of 37 cases,
• 74% of tumors showed
immunohistochemical expression of
interleukin-6 while
• 17% had abnormal DNA content
Epidemiology
• US ~ 75 case / million autopsies
• 75% sporadic – Female
• Mean age – 56
• 15% present as sudden death
– tumour embolism, HF, mechanical
obstruction
History
Asymptomatic (20%)
symptomatic
sudden death (15%)
Mechanical interference with cardiac fx
LHF
Exertional SOB
Orthopnea
PND
Pul edema
Postural dizziness
RHF
fatigue
peripheral edema
ascites
systematic (L)
infarct / haemorrhage
of viscera
e.g. CVA
visual loss
embolization
Pulmonary (R)
PE
Pul infarction
Pul HT
Constitutional symptoms : fever, Wt loss, arthralgias, Raynaud ~ 50% of patient due to
interleukin-6 overporduction
Physical
• ↑JVP
• Loud S1
( delay mitral valve closure)
• Early diastolic sound (Tumor plop)
tumor hit
against the endocardial wall
• Diastolic atrial rumble ( obstruction in MV)
• MR/ TR ( valvar damage/ prolapse)
DDX
• Mitral Regurgitation
• Mitral Stenosis
• Pul Embolism
• Pul HT , primary
• Tricuspid Regurgitation
• Tricuspid Stenosis
Ix
• Lab: ESR, CRP, CBC, serum
interleukin-6
• CXR
• ECHO
• need to differentiate thrombus from
myxoma
– Thrombus ( in posterior portion, in layers)
– Myxoma ( presence of stalk and mobility)
• MRI (point of attachment )
• CT scan
Treatment
• Medical treatment for CHF and
arrhythmia
• Surgical excision is the definitive tx
• Safe and curative
• Recurrence is possible if incomplete
excision
Thank you