Letter to Editor
Cardiac myxoma: A shadow cast elsewhere The Editor, We have read with great interest the brief communication by Kumar et al.[1] We would like to add our experience on left atrial myxoma. A 55‑year‑old female presented in the emergency department with complaints of diffuse abdominal pain and two episodes of vomiting for 1‑day. She was a hypertensive and diabetic and on regular treatment for the past 20 years. She had experienced multiple such episodes of pain abdomen in the past. Upper gastrointestinal endoscopy revealed mild hiatal hernia at that time. On examination, her heart rate was 94/min, blood pressure was 150/100 mm Hg and a loud first heart sound was heard in the mitral area. Abdominal examination was notable only for diffuse abdominal tenderness without guarding or rigidity. Chest X‑ray showed cardiomegaly and other labs were normal. Ultrasonography of the abdomen revealed no other abnormality except for grade1 fatty liver. Electrocardiogram (ECG) showed ST segment depression in leads V5 and V6, inverted P wave in lead V1 and broad P wave in lead II [Figure 1]. Echocardiography showed a left atrial mass measuring 4.1 cm × 2.6 cm blocking the mitral valve flow [Figure 2] and creating a peak gradient of 18 mm Hg. Coronary angiography showed a double vessel disease necessitating coronary intervention. Surgical excision of the myxoma was
Figure 1: Electrocardiogram showing ST segment depressions in leads V5 and V6 and inverted P waves in lead V1 and a broad P wave in lead II Annals of Cardiac Anaesthesia | Apr-Jun-2015 | Vol 18 | Issue 2
done (the jelly‑like left atrial myxoma arising from posterior wall was excised in toto along with the peduncle attached to the wall) along with coronary artery bypass for the involved coronaries. Postoperatively she was much better with her abdominal pain subsided, and the typical ECG changes reverted. Her ECG recorded 1‑year back showed P wave inversion in lead V1. P wave in lead V1 is normally biphasic, and the terminal negative component corresponding to activation of the left atrium is directed posteriorly. In left atrial abnormality the vector is consequently directed away from lead V1. [2] The broad P wave in lead II and the P inversion are known to correlate with the tumor size, the left atrial dimension and/or the left atrial pressure as occurred with our patient.[3] Left atrial myxomas that comprise 75% of cardiac myxomas, are known to typically present with dyspnea, syncope and features of systemic embolization. [4] Our case was unique in that the quintessential features were absent and that abdominal pain (not amounting to the typical postprandial angina) was the cardinal symptom. Rare case reports of atrial myxomas that presented with abdominal
Figure 2: Echocardiography showing a left atrial mass measuring 4.1 cm × 2.6 cm blocking the mitral valve flow 265
Letters to Editor
pain have been reported.[5] In our case, we postulate that apart from her coronary artery disease, systemic micro‑embolization, and mesenteric ischemia may have contributed to her abdominal pain. Although the only way to confirm that would be mesenteric angiography, which was not done in our case, we put forward our theory that left atrial myxomas may have such a varied presentation. Abdominal aortic occlusion secondary to left atrial myxoma has been documented in other reports.[5] When infected, myxomas may be masked as infective endocarditis as well. We reiterate that high index of clinical suspicion and knowledge of atypical presentations of atrial myxomas and their complications can help avert catastrophes.
Dilip Gude, Preeti Reddy Komireddy, E. A. Padma Kumar1 Department of Internal Medicine, Princess Durru Shehvar General Hospital, 1Department of Cardiology, Mediciti Hospitals, Hyderabad, Telangana, India Address for correspondence: Dr. Dilip Gude, Princess Durru Shehvar General Hospital, Purana Haveli, Hyderabad ‑ 500 002, Telangana, India. E‑mail: [email protected]
ACKNOWLEDGMENTS We thank the Departments of Cardiology, Internal Medicine
266
and Critical Care Durru Shehvar and Medicity Hospitals for their great support.
REFERENCES 1. Kumar B, Raj R, Jayant A, Kuthe S. Left atrial myxoma, ruptured chordae tendinae causing mitral regurgitation and coronary artery disease. Ann Card Anaesth 2014;17:133‑6. 2. Schamroth L, Narasimhan C, Francis J, editors. An Introduction to Electrocardiography. 8th ed. New Delhi: Wiley India; 2013. p. 29. 3. Komiya N, Isomoto S, Hayano M, Kugimiya T, Yano K. The influence of tumor size on the electrocardiographic changes in patients with left atrial myxoma. J Electrocardiol 2002;35:53‑7. 4. Coley C, Lee KR, Steiner M, Thompson CS. Complete embolization of a left atrial myxoma resulting in acute lower extremity ischemia. Tex Heart Inst J 2005;32:23840. 5. Kao CL, Chang JP. Abdominal aortic occlusion: A rare complication of cardiac myxoma. Tex Heart Inst J 2001;28:324‑5. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.154499
Annals of Cardiac Anaesthesia | Apr-Jun-2015 | Vol 18 | Issue 2
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Cardiac myxoma: A shadow cast elsewhere The Editor, We have read with great interest the brief communication by Kumar et al.[1] We would like to add our experience on left atrial myxoma. A 55‑year‑old female presented in the emergency department with complaints of diffuse abdominal pain and two episodes of vomiting for 1‑day. She was a hypertensive and diabetic and on regular treatment for the past 20 years. She had experienced multiple such episodes of pain abdomen in the past. Upper gastrointestinal endoscopy revealed mild hiatal hernia at that time. On examination, her heart rate was 94/min, blood pressure was 150/100 mm Hg and a loud first heart sound was heard in the mitral area. Abdominal examination was notable only for diffuse abdominal tenderness without guarding or rigidity. Chest X‑ray showed cardiomegaly and other labs were normal. Ultrasonography of the abdomen revealed no other abnormality except for grade1 fatty liver. Electrocardiogram (ECG) showed ST segment depression in leads V5 and V6, inverted P wave in lead V1 and broad P wave in lead II [Figure 1]. Echocardiography showed a left atrial mass measuring 4.1 cm × 2.6 cm blocking the mitral valve flow [Figure 2] and creating a peak gradient of 18 mm Hg. Coronary angiography showed a double vessel disease necessitating coronary intervention. Surgical excision of the myxoma was
Figure 1: Electrocardiogram showing ST segment depressions in leads V5 and V6 and inverted P waves in lead V1 and a broad P wave in lead II Annals of Cardiac Anaesthesia | Apr-Jun-2015 | Vol 18 | Issue 2
done (the jelly‑like left atrial myxoma arising from posterior wall was excised in toto along with the peduncle attached to the wall) along with coronary artery bypass for the involved coronaries. Postoperatively she was much better with her abdominal pain subsided, and the typical ECG changes reverted. Her ECG recorded 1‑year back showed P wave inversion in lead V1. P wave in lead V1 is normally biphasic, and the terminal negative component corresponding to activation of the left atrium is directed posteriorly. In left atrial abnormality the vector is consequently directed away from lead V1. [2] The broad P wave in lead II and the P inversion are known to correlate with the tumor size, the left atrial dimension and/or the left atrial pressure as occurred with our patient.[3] Left atrial myxomas that comprise 75% of cardiac myxomas, are known to typically present with dyspnea, syncope and features of systemic embolization. [4] Our case was unique in that the quintessential features were absent and that abdominal pain (not amounting to the typical postprandial angina) was the cardinal symptom. Rare case reports of atrial myxomas that presented with abdominal
Figure 2: Echocardiography showing a left atrial mass measuring 4.1 cm × 2.6 cm blocking the mitral valve flow 265
Letters to Editor
pain have been reported.[5] In our case, we postulate that apart from her coronary artery disease, systemic micro‑embolization, and mesenteric ischemia may have contributed to her abdominal pain. Although the only way to confirm that would be mesenteric angiography, which was not done in our case, we put forward our theory that left atrial myxomas may have such a varied presentation. Abdominal aortic occlusion secondary to left atrial myxoma has been documented in other reports.[5] When infected, myxomas may be masked as infective endocarditis as well. We reiterate that high index of clinical suspicion and knowledge of atypical presentations of atrial myxomas and their complications can help avert catastrophes.
Dilip Gude, Preeti Reddy Komireddy, E. A. Padma Kumar1 Department of Internal Medicine, Princess Durru Shehvar General Hospital, 1Department of Cardiology, Mediciti Hospitals, Hyderabad, Telangana, India Address for correspondence: Dr. Dilip Gude, Princess Durru Shehvar General Hospital, Purana Haveli, Hyderabad ‑ 500 002, Telangana, India. E‑mail: [email protected]
ACKNOWLEDGMENTS We thank the Departments of Cardiology, Internal Medicine
266
and Critical Care Durru Shehvar and Medicity Hospitals for their great support.
REFERENCES 1. Kumar B, Raj R, Jayant A, Kuthe S. Left atrial myxoma, ruptured chordae tendinae causing mitral regurgitation and coronary artery disease. Ann Card Anaesth 2014;17:133‑6. 2. Schamroth L, Narasimhan C, Francis J, editors. An Introduction to Electrocardiography. 8th ed. New Delhi: Wiley India; 2013. p. 29. 3. Komiya N, Isomoto S, Hayano M, Kugimiya T, Yano K. The influence of tumor size on the electrocardiographic changes in patients with left atrial myxoma. J Electrocardiol 2002;35:53‑7. 4. Coley C, Lee KR, Steiner M, Thompson CS. Complete embolization of a left atrial myxoma resulting in acute lower extremity ischemia. Tex Heart Inst J 2005;32:23840. 5. Kao CL, Chang JP. Abdominal aortic occlusion: A rare complication of cardiac myxoma. Tex Heart Inst J 2001;28:324‑5. Access this article online Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.154499
Annals of Cardiac Anaesthesia | Apr-Jun-2015 | Vol 18 | Issue 2
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
