Right atrial myxoma and pulmonary embolism. Rational basis for investigation and treatment.

Abstract

SUMMARY We report a case in which pulmonary embolectomy was crucial in the successful outcome of an operation to remove a right sided atrial myxoma. The association between such myxomata and embolisation is emphasised and guidelines for the rational investigation and treatment of such lesions are given.The occurrence of peripheral emboli is relatively common and well documented with left atrial myxoma,'-3 and it is not surprising, therefore, that right atrial myxoma should give rise to pulmonary emboli.4 Indeed, the association of pulmonary emboli with right atrial myxoma has been recognised at necropsy for many years; Chiari5 reported the first case in 1931. The clinical recognition of this association, however, is less well documented4 6 7 and a search of the published reports discloses only two pulmonary embolectomy8 9 performed during an operation to remove a right sided myxoma, and in neither case was the outcome successful. We report here the successful removal of a right atrial myxoma in a case where pulmonary embolectomy was crucial.Case report A 52 year old housewife was admitted with sudden swelling of the right arm accompanied by a dull ache. She complained of increasing tiredness for the six months before admission, with progressive exertional dyspnoea for the last three weeks. Her Chest radiography showed moderate cardiomegaly (cardiothoracic ratio of 155/280) without any specific chamber enlargement, while the electrocardiogram showed sinus rhythm with a Q wave in lead III and T wave inversion in the anterior chest leads.A technetium-99mMAA venogram through a distal right arm vein showed an abnormality of flow in the right axillary vein, suggesting thrombosis, and a contrast venogram via the right median cubital vein confirmed thrombosis of the brachial and axillary veins, which extended as far as the superior vena cava. A pulmonary perfusion scan, using technetium99mMAA, showed diminished flow to the entire left lung in keeping with massive pulmonary embolism, while flow to the right lung appeared normal. Echocardiography showed the presence of a large filling defect of the right atrium, prolapsing into the ventricle during diastole. Cardiac catheterisation was carried out via the left median basilar vein and the right femoral artery. The systolic pulmonary arterial pressure and the mean right atrial pressure were 15 and 14 mmHg.respectively. Contrast injection showed a large irregular filling defect occupying two thirds of the right atrium and prolapsing through the tricuspid valve. In addition, there was stagnation of blood flow in this area. A biopsy was taken using a "Bioptome" introduced viE

Role of Cardiac Ultrasound in the Detection of Pulmonary Embolism

“…If peripheral thrombosis has progressed to involve the inferior vena cava, echocardiography may demonstrate continuity between the caval thrombus and the mobile right atrial mass. 58 However, similar echocardiographic findings can also be observed in patients with right-sided myxomas and other cardiac tumors, [59][60][61][62][63][64] and differentiation of intracavitary masses on the basis of ultrasound characteristics alone is often not possible.…”

Right Atrial Myxoma Presenting with Recurrent Episodes of Pulmonary Embolism

“…Hansen et al [4] reported that pulmo nary embolism occurred in 6 of 35 cases (17.1 %) of right atrial myxoma in their series, and that in 1 patient (2.9%) it was the initial symptom. The relatively low incidence of pul monary emboli from a right atrial myxoma may be because pulmonary embolism is more likely to be asymptomatic, misdiagnosed or diagnosed later than systemic emboli [7], Of main concern in a right atrial myxoma is the long duration of illness before correct diagnosis is made, because embolism by tu mor fragments or overlying thrombus forma tion is a potentially fatal complication of this condition. Hansen et al [4] reported that the duration of the symptoms until correct diag- [3.…”

“…There have been reports in the literature of a right atrial myxoma compli cated with pulmonary embolism [5][6][7]. How ever.…”

Fulminantes Rechtsherzversagen bei pulmonaler mikroskopischer Tumorzellembolie - eine seltene Differenzialdiagnose

“…In seltenen Fällen führt die komplette Resektion des Primärtumors zu einer Remission [11]. Groûe Tumoremboli können gelegentlich erfolgreich chirurgisch entfernt werden [18,19] . Bei den meisten Patienten muss sich die Behandlung allerdings auf supportive Maûnahmen wie Sauerstoffgabe, Drainage von Pleuraergüssen und die Gabe von Opiaten beschränken.…”