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CASE REPORT
Year : 2022 | Volume
: 32
| Issue : 3 | Page : 172-174
Concomitant multiple coronary artery embolizations and bilateral lower limb ischemia due to dislodged left atrial myxoma-like thrombus
Mehmet Koray Adali, Ipek Buber
Department of Cardiology, Faculty of Medicine, Pamukkale University, Denizli, Turkey
Correspondence Address:
Mehmet Koray Adali
Department of Cardiology, Faculty of Medicine, Pamukkale University, Denizli 20160
Turkey
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jcecho.jcecho_21_22
The differential diagnosis of intracardiac masses is challenging. Cardiac myxomas are benign primary heart tumors and most often are confused with thrombi in diagnosis. In some cases, the embolic complication of intracardiac masses can be fatal. We present a patient who had two nightmare complications simultaneously. A mobile left atrial mass detected and decided surgical excision. But the mass had vanished one day after and caused ST-elevation myocardial infarction (STEMI) and bilateral lower limb ischemia.
Keywords: Coronary embolism, left atrial myxoma, lower limb ischemia
Cardiac myxomas are the most common primary and benign heart tumors, presenting 75%–90% in the left atrium (LA) cavity. The differential diagnosis of intracardiac masses includes vegetation, thrombi, myxoma, and extracardiac metastatic tumors.[1] Transthoracic echocardiography (TTE) is the most used noninvasive diagnostic method that allows identifying and examining cardiac masses in terms of shape, localization, mobility, size, and possible hemodynamic effects. Some specific intracardiac localizations and echocardiographic features may be helpful in the differential diagnosis.[2]
Cardiac myxoma clinical manifestations may occur with obstructive, constitutional, and embolic symptoms. Mitral valve obstruction with myxoma may cause dyspnea, dizziness, syncope, palpitations, and heart failure symptoms. In addition, constitutional and systemic manifestations occur with nonspecific symptoms, and important and urgent systemic or cerebral embolic events closely associated with mortality may be a bad surprise for myxomas.[3] The central nervous system, extremities, visceral organs, and coronary arteries may be affected by embolic complications.[4]
In this case, we present a patient who had a mass in the LA with no cardiac disease history. Our first step diagnosis was atrial myxoma. Nevertheless, early after diagnosis, the patient had two major nightmare embolic complications in the preoperative stage, including ST-elevation myocardial infarction and bilateral lower limb arterial embolization. Rapid progression of cardiogenic shock and bilateral lower limb ischemia caused the patient loss.
Case ReportA 48-year-old female was hospitalized in the intensive care unit due to pneumonia, interstitial lung disease, and hypoxia. The patient was consulted to the cardiology clinic due to the appearance of hypodense and solid soft tissue of approximately 45 mm × 25 mm in size, extending from the LA to the left ventricle and causing narrowing at the aortic outlet level in the chest computed tomography (CT). The mean Hounsfield unit value of the mass on CT was 31.4, consistent with thrombus [Figure 1]. Bedside echocardiography showed normal left ventricular ejection fraction (60%) and a hyperechogenic mass, 42 mm × 26 mm in size, mobile, extending to the left ventricle and obstructing mitral valve flow, compatible with myxoma, and had definite margins. The LA size was 46 mm × 52 mm. Surgical treatment was recommended after the general condition of the patient improved. However, one night later, an unexpected event series like a nightmare occurred.
Figure 1: A giant mass is seen in the left atrium on chest CT (arrows). The mass was pedunculated, hypodense, and related to atrial septums. CT = Computed tomographyThe patient had chest pain, and the electrocardiogram showed ST-segment elevation in leads I, aVL, V2-6, II, III, and aVF [Figure 2]. Vital signs became unstable (blood pressure dropped to 80/60 mmHg and heart rate was 100 bpm). Urgent bedside echocardiography was performed. The ejection fraction was 30%, the apex and anterior and inferior walls were hypokinetic, and the mass had vanished. The remnant of the mass was seen [Video 1]. Coldness and bruising started on both the patient's lower extremities, and bilateral lower extremities' peripheral pulses (including femoral arteries) were not available. Emergency cardiovascular surgery consultation was requested, and the patient was examined with a bedside handheld vascular Doppler device. No flow was observed in both lower extremity arteries. Which clinical situation was the priority? We had to make a decision. Antiaggregant, anticoagulant treatment, and diuretic infusion were administered urgently, and coronary angiography was given priority as the patient developed pulmonary edema and exacerbation of chest pain. The coronary angiography was performed by transradial access with the routine Judkins technique. The left main coronary artery and right coronary artery were normal, but distal segments of the left anterior descending, diagonal, and circumflex coronary artery were 100% occluded due to the embolization [Figure 3]. The coronary intervention was not performed because coronary occlusions were considered distally and secondary to embolism. A peripheral angiography for the lower limbs could not be performed because the patient's hemodynamic situation worsened. The patient was urgently operated on for coronary artery bypass grafting and mass excision from the abdominal aorta. Unfortunately, the patient died in cardiac surgery before the dislodged mass was removed. A pathological examination report of the remnant LA mass and left anterior descending coronary artery embolization material showed that the mass was thrombus.
Figure 2: D-day. The ECG of the patient. It showed ST-segment elevation in leads I, aVL, V2-6, II, III, and aVF. ECG = Electrocardiogram
Figure 3: The coronary angiogram of the patient. The right coronary artery was normal (up left). The distal part of the left anterior descending, diagonal, and the circumflex coronary artery was obstructed (arrows) Discussion Masses other than myxoma located in the LA can be confused with myxomas, and myxomas involving areas outside the LA can be confused with other masses. There is a diagnostic dilemma in distinguishing thrombus or myxoma in a cardiac mass originating from the LA in the current case. First, the mass was related to the interatrial septum, mobility extended to the left ventricle and definite margins. Second, the patient did not have thromboembolic cardiac risk factors such as atrial fibrillation (AF), heart valve disease, or mechanical prosthetic valves. Third, atrial myxomas occur more commonly in female patients from the third to sixth decades. Our case was also in this age group. For these reasons, we thought of atrial myxoma as a first step diagnosis and decided on surgery.
Lee et al. showed among 186 patients that 4.2% of the patients diagnosed with myxoma by preoperative TTE had cardiac tumors other than myxoma, and 2.2% of the masses were atrial thrombus. Myxoma-like thrombi had larger LA diameters, a higher frequency of AF, and larger-sized masses than myxomas. The LA mass in our patient was similar in size to those in the previous studies investigating atrial myxomas.[5],[6],[7]
Many cases of myocardial infarction as a result of atrial myxoma or thrombus embolization have been presented in the literature.[8],[9] It has been reported that myxoma-like thrombi are rarely seen in the right atrium and cause syncope and pulmonary embolism.[10] Left atrial myxoma-like thrombus and its embolization to both multiple coronary and bilateral lower limb arteries have not been reported in the literature. In our case, two life-threatening complications occurred to coincide.
We had some limitations about this case. First, we diagnosed the mass as a myxoma for transthoracic echocardiographic features, and we did not perform any further diagnostic procedures such as transesophageal or contrast echocardiography or cardiac magnetic resonance imaging. Second, after the coronary angiography, we could not perform a peripheral angiography to show embolic materials due to the patient's hemodynamic situation. Third, embolic materials could not be demonstrated because the patient was lost due to the rapidly worsening cardiac condition.
ConclusionMasses of this size and echocardiographic features in the LA should be treated surgically as soon as possible because they cause systemic embolism. When compared to right atrial mass, LA mass may lead to fatal clinical consequences. Multiple coronary embolizations from atrial thrombi can trigger a cardiogenic shock in patients and do not enable percutaneous coronary intervention due to embolic material.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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