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Large, bilateral central pulmonary thromboemboli (PTE) led to cor pulmonale and severe hypoxemia in a patient who had undergone Hardy's operation. After several unsuccessful efforts (thrombolysis using a percutaneous catheter and aspiration of the emboli), mechanical clot fragmentation using a percutaneous transluminal angioplasty (PTA) balloon was attempted. This procedure was successful, resulting in a decrease in pulmonary artery pressure from 58/22 (mean 34) mmHg to 20/10 (mean 13) mmHg together with an increase in aortic pressure from 64/36 (mean 45) mmHg to 112/60 (mean 77) mmHg. Thus, mechanical clot fragmentation using a PTA balloon is a promising method for reducing pulmonary artery pressure and increasing aortic pressure in patients with acute PTE.

lthough myxomas are the most common primary tumor of the heart, only a few cases are complicated by atrial septal defect (ASD) or patent foramen ovale. 1 Tumors involving both atria are also rare and found in less than 2.5% of all cases of myxoma. 2 We describe a case of a myxoma originating in the left atrium and growing through a secundum ASD into the right atrium. Case ReportA 55-year-old man was referred for urgent surgical resection of a right atrial tumor. Over the previous 3 months he had noticed mild shortness of breath on exertion. Physical examination revealed a blood pressure of 144/100 mmHg and pulse rate of 90 beats/min. Cardiac examination disclosed no pathological murmur. Laboratory analysis showed an elevated C-reactive protein concentration, and normal gamma globulins. A chest roentgenogram showed no cardiac enlargement with a 45.7% cardiothoracic ratio. Electrocardiography showed a normal sinus rhythm without right bundle-branch block. Transthoracic echocardiography demonstrated a 40-mm diameter, round tumor in the right atrium, but was unable to identify the point of attachment of the mass or the ASD. Transesophageal echocardiography (TEE) clearly demonstrated a large mass in the right atrium, which was attached by a pedicle to the base of the right pulmonary vein via a secundum ASD (Fig 1). Color flow mapping also showed a left-to-right shunt through the ASD. Coronary angiography showed 50% luminal narrowing of the left anterior descending artery and left circumflex artery which was feeding the tumor.At operation, cardiopulmonary bypass with moderate hypothermia was established, and the heart was arrested with cold blood cardioplegia. The right atrium was opened wide and a darkish brown gelatinous mass was found attached by a pedicle through a secundum ASD (12 mm in diameter) onto the lateral wall of the left atrium near the right pulmonary vein. The tumor was completely excised

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