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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 108-110

First successful atrial myxoma excision in Nigeria: A 21-year follow-up


Division of Cardiovascular and Thoracic Surgery, Department of Surgery, UNTH, Enugu, Nigeria

Date of Web Publication3-Jul-2019

Correspondence Address:
Dr. Dabeluchi Chiedozie Ngwu
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, UNTH, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njc.njc_1_18

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  Abstract 


A young man presented to our institution in New York Heart Association (NYHA) Class III, following a referral from a peripheral hospital where he had been on asthma treatment for over 8 years until he developed digital clubbing, and further clinical evaluation suggested cardiac disease. The preoperative diagnosis of left atrial myxoma was confirmed with transthoracic echocardiography. He had successful excision of the tumor, made a quick recovery, and has remained in NYHA Class I, with no cardiac events.

Keywords: Atrium, excision, myxoma


How to cite this article:
Ngwu DC, Okwulehie VA, Aghaji MA. First successful atrial myxoma excision in Nigeria: A 21-year follow-up. Nig J Cardiol 2018;15:108-10

How to cite this URL:
Ngwu DC, Okwulehie VA, Aghaji MA. First successful atrial myxoma excision in Nigeria: A 21-year follow-up. Nig J Cardiol [serial online] 2018 [cited 2019 Sep 21];15:108-10. Available from: http://www.nigjcardiol.org/text.asp?2018/15/2/108/261999




  Introduction Top


Cardiac tumors in general are rare. Myxomas represent the most frequently encountered pathological type of tumors in the heart.[1] They arise most commonly from the left atrium, but occasionally arise from other cardiac chambers, and rarely from the valves.

The reported clinical presentation includes embolic phenomena, unexplained neurologic symptoms, hemodynamic obstruction, and a vague systemic illness.[2] The diagnosis therefore can easily be missed owing to this array of possible presenting features, which enable the tumor to masquerade as other more common cardiac and noncardiac conditions, including rheumatic heart disease, infective endocarditis, and collagen vascular disease.


  Case Presentation Top


We present a 25-year-old male who was referred to our institution from a peripheral hospital, with an 8-year history of effort intolerance and chest pain. He had been on the treatment for asthma at the said hospital until he developed digital clubbing which prompted further evaluation. Electrocardiography suggested left ventricular hypertrophy, and chest radiograph showed cardiomegaly. He was subsequently referred to our facility for expert cardiovascular evaluation and care and was in New York Heart Association Class III at the time of presentation.

Transthoracic echocardiography [Figure 1] showed a large, intracavitary, hyperechoic, left atrial mass measuring 5.2 cm × 3.3 cm, bouncing back and forth on the posterior wall (the specific site of attachment was not apparent on transthoracic echocardiography and the facility for transesophageal echocardiography was not available to us at that time). The mitral valve apparatus was essentially normal.
Figure 1: Preoperative Transthoracic echo, 1995

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Erythrocyte sedimentation rate was markedly elevated at 129 mm/min. Other hematologic parameters were within normal limits.

The tumor was excised via a median sternotomy approach under cardiopulmonary bypass with moderate hypothermia. Intraoperatively, the tumor was seen to have arisen from the interatrial septum and part of the posterior wall of the left atrium. It was excised with a cuff of normal tissue and the resulting atrial septal defect was closed using a patch of autologous pericardium, care was taken to avoid intraoperative fragmentation of the tumor, and direct visual inspection of all cardiac chambers was carried out.

Pathological examination of the resected tumor specimen confirmed the diagnosis of cardiac myxoma.

The postoperative course was uneventful, he has remained well, and he is currently being followed up clinically and with serial echocardiographic surveillance for recurrence [Figure 2].
Figure 2: Last follow-up Transthoracic Echo, 2016

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  Discussion Top


The first antemortem diagnosis of atrial myxoma was made in 1951[3] and 3 years later, in 1954, Clarance and Crawford performed the first operative excision of the left atrial myxoma.[4]

These tumors have no pathognomonic clinical features [5] but are pathophysiologically characterized by a triad of hemodynamic obstruction, embolization, and constitutional symptoms.[5]

Transthoracic echocardiography is usually sufficient for preoperative diagnosis, but may need to be supplemented with other investigations, including transoesophageal echocardiography, angiography, CT scan and MRI.[6]

Since the first successful operative excision of a left atrial myxoma in 1954, techniques and knowledge have improved and surgery is currently the standard of care, with low operative mortality. It requires meticulous intraoperative handling of the tumor to minimize the risk of fragmentation and systemic embolization which, along with myocardial infarction, are the major causes of postoperative morbidity and mortality. Care is also taken to ensure excision with adequate margin, as this minimizes the risk of recurrence.[6]

Owing to a combination of factors, including the relative rarity of this condition, the absence of specific symptoms and signs, and the inordinate underdevelopment of cardiovascular care in Sub-Saharan Africa, the chances of delayed or even missed diagnosis may be much higher here than in the developed world. The patient in question had been on treatment for asthma for nearly a decade before an accurate diagnosis could be established. He eventually underwent the first successful surgical excision of an atrial myxoma in the country.

This case in being reported for its historical significance to cardiovascular care in Nigeria.


  Conclusion Top


Although cardiac tumors in general are rarely encountered in clinical practice, myxomas are the least uncommon of all. They are intracavitary tumors most frequently encountered in the atria, particularly the left. They present a diagnostic challenge in many instances owing to the absence of specific clinical features of the disease.

Echocardiography has emerged as the gold standard for the preoperative diagnosis, and patients who develop new cardiac symptoms and signs need immediate echocardiographic evaluation. A missed diagnosis would usually mean an unrelenting journey to cardiac death, while early diagnosis and timely intervention offer the best chance at cure, with an operative death risk of 0.3%.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Benjamin HG. Primary fibromyoma of the heart. Arch Pathol 1939;27:950.  Back to cited text no. 1
    
2.
O'Neil MB, Grehl TM, Hurley EJ. Caardiac myxoma: A clinical diagnostic challenge. Am J Surg 1979;138:68.  Back to cited text no. 2
    
3.
Geoldberg HP, Glenn H, Dotter TF, Steinberg C, Israel. Myxoma of the Left Atrium: Diagnosis made during life with operative and postmortem findings. Circulation 6:726-67. 10.1161101.CIR.6.5.762.  Back to cited text no. 3
    
4.
Crafoord C, Glorer RP. Discussion of late results of mitral commissurotomy in left atrial myxoma. Henry ford hospital international symposium on cardiovascular surgery. Philadelphia: WB Sounders; 1955. p. 202-11.  Back to cited text no. 4
    
5.
Laurent P, Pierre D, Robert L. Clinical presentation of left Atrial myxoma: A series of 112 consecutive cases. Medicine 2001;80:159-72.  Back to cited text no. 5
    
6.
Murphy MC, Seeny MS, Putnam JB, Walker WE, Fraizer OH, David AO, et al. Surgical treatment of cardiac tumors: A 25-year experience. Texas Heart Institute the University of Texas Health Science Center and MD Anderson Cancer Institute, Houston, Texas. The annals of thoracic surgery 1990;49:612-7; discussion 617-8.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
Introduction
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Discussion
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