Nigerian Journal of Cardiology

CASE REPORT
Year
: 2014  |  Volume : 11  |  Issue : 1  |  Page : 46--48

Acute myocardial infarction in a 28-year-old man from embolized left atrial myxoma


Puneet Rastogi1, Ganesh Dhanuka2, Manish K Multani2, Raviprakash Pandey2,  
1 Department of Cardiology, Post Graduate Resident in Medicine, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India
2 Department of Medicine, Post Graduate Resident in Medicine, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India

Correspondence Address:
Puneet Rastogi
41, Vikas Nagar, Gwalior - 474 002, Madhya Pradesh
India

Abstract

Atrial myxoma has been reported as source of coronary emboli, a rare complication, causing acute myocardial infarction (MI). We report case of a 28-year-old male, who presented with acute chest pain, radiating to left arm, with sweating and palpitation. Transthoracic echocardiography (TTE) showed an irregular homogenous pedunculated mass of size 3.7 × 2.1 cm attached to the interatrial septum towards the base of the anterior mitral leaflet, prolapsing into left ventricle (LV) during diastole, but not obstructing the flow. Emergency coronary angiography revealed a tubular lesion (thrombus containing) in left anterior descending (LAD) coronary artery. The patient was diagnosed as acute anteroseptal MI due to LAD coronary artery embolization originating from left atrial myxoma. Coronary artery bypass graft (CABG) along with surgical resection of friable myxomatous mass was done. Histopathological examination was consistent with atrial myxoma. Present case justifies that atrial myxomas should be considered as a differential diagnosis while dealing with MI in young patients.



How to cite this article:
Rastogi P, Dhanuka G, Multani MK, Pandey R. Acute myocardial infarction in a 28-year-old man from embolized left atrial myxoma.Nig J Cardiol 2014;11:46-48


How to cite this URL:
Rastogi P, Dhanuka G, Multani MK, Pandey R. Acute myocardial infarction in a 28-year-old man from embolized left atrial myxoma. Nig J Cardiol [serial online] 2014 [cited 2021 Apr 21 ];11:46-48
Available from: https://www.nigjcardiol.org/text.asp?2014/11/1/46/130122


Full Text

 Introduction



Atrial myxomas are usually asymptomatic, but their presentation can be catastrophic owing to their ability of embolization to cerebral, peripheral, and coronary arteries. [1] Arterial embolism, a common complication of left atrial myxomas (40-65%), is caused either by thrombus formation at the surface of the tumor or by fragmentation of villous myxoma. [2] Atrial myxomas are a rare source of coronary artery embolism (0.06%). [2],[3] We report a case of 28-year-old male who presented in the intensive care unit (ICU) with acute onset of chest pain, radiating to left arm, with severe sweating and palpitations. The patient was diagnosed as acute anteroseptal myocardial infarction (MI). Findings of transthoracic echocardiography (TTE) and angiography reported embolization of left anterior descending (LAD) coronary artery from a left atrial myxoma as a main culprit behind the scene.

 Case Report



A 28-year-old male presented to the ICU with acute onset chest pain for 4 h, while playing cricket, radiating to left arm, associated with severe sweating and palpitation. Patient was thin-built, nonsmoker, and nondiabetic. On physical examination, blood pressure was 110/72 mmHg, pulse was 98/min, and other physical findings were unremarkable. Electrocardiography (ECG) showed heart rate of 98/min; regular with ST segment elevation in leads V1-3; and ST segment depression in leads II, III, and aVf [Figure 1]. Immediate troponin T testing result was positive. The patient was thrombolysed with streptokinase 1.5 million units over 1 h. The other investigations including hemogram, lipid profile, and chest radiography were normal. TTE showed an irregular homogenous pedunculated mass of size 3.7 × 2.1 cm attached to the interatrial septum towards the base of the anterior mitral leaflet, prolapsing into left ventricle (LV) during diastole, but not obstructing the flow [Figure 1]. Trace mitral regurgitation, trace tricuspid regurgitation, and mild pulmonary artery hypertension (pulmonary artery systolic pressure 37 mmHg) were recorded, with hypokinesia of distal half of interventricular septum and apex (estimated ejection fraction 50%). Above findings suggested that the patient had suffered MI likely due to embolism from atrial myxoma. Emergency coronary angiography revealed a tubular lesion (thrombus containing) in the middle of LAD coronary artery (99% block; severe single vessel disease) [Figure 2].{Figure 1}{Figure 2}

After 7 days, left atrial mass was resected (left atrium was opened by an oblique atriotomy behind the interatrial groove, the tumor was excized and the pedicle shaved off; while inspecting from right atrium, pericardial patch was used to close the defect) successfully along with coronary artery bypass graft (CABG; pedicled left internal mammary artery - LAD). On making arteriotomy in LAD coronary artery, a 2 mm piece of tumor tissue was extruded from proximal part. Histopathologic evaluation confirmed the myxomatous nature of resected mass [Figure 2]. The patient recovered without any complications and had favorable outcome.

 Discussion



Cardiac myxoma, a histopathologically benign tumor of the heart, makes up more than 50% of primary cardiac neoplasms, with majority arising in the left atrium. [3],[4] The mean age of presentation of a sporadic myxoma is 50 years and two-thirds of patients are females. [2],[3] Polypoid type of myxoma is soft and irregular, with a mobile surface, associated with more chance for embolization than solitary tumor. Though tumor size does not correlate with the embolization potential, a prolapsing and polypoid tumor has been associated with a higher incidence of embolism. [5] The clinical features of myxomas are determined by their location, size, and mobility. [3] Patients with myxoma mostly present with systemic embolization, intracardiac obstruction, creating mitral regurgitation, constitutional symptoms (dyspnea, palpitation, and chest pain), and arrhythmias. [1],[3] Studies reported that in left atrial myxoma, systemic embolization occurred in 40-63% of patients, most commonly cerebral infarction followed by limb ischemia. [6],[7] In 40% patients embolic events were the first manifestation of the tumor. [6],[7]

Coronary artery embolization causing MI, is an extremely rare presentation of a myxoma (0.06%). [2],[8] This is attributed to the perpendicular position of the coronary ostia in relation to the aortic blood flow and the protection of the ostia by the aortic leaflets in systole. [9] Similar anatomy was not seen in this patient. Studies reported inferior wall MI as the most common presentation (63.3%) in left atrial myxoma-related MI. [6] Right coronary artery embolization was most common in 47.6% of cases, followed by LAD artery in 19%, and the left circumflex coronary artery in 9.5% of cases with no coronary artery abnormality in 23.8% of the cases on coronary angiography. Early age of presentation, absence of cardiovascular risk factors, male sex, polypoid, and prolapsing nature of the tumor leading to embolism in LAD artery in the reported case makes it a rare presentation.

Thrombolytic therapy is not recommended for patients with cardiac myxomas because of the increased risk of embolism, [10] owing to lysis of the accumulated thrombus, [11] and the presence of hemorrhagic areas with a rich vascular supply. Thrombolysis can increase the hemorrhage and can cause the rupture of small fragments. [10] In the present case, thrombolysis was done due to unavailability of primary percutaneous coronary intervention.

Echocardiography, computed tomography (CT), and cardiac magnetic resonance imaging (MRI) are the most useful diagnostic tools in the assessment of cardiac tumors, which in almost all cases precisely locates the tumor and defines its extent and thus resectability. [12] Transesophageal echocardiography (TEE) is 100% sensitive, while TTE is 95% sensitive in detecting the tumor. [13] Coronary angiography is mandatory in all myxoma patients presenting with MI, because studies reported that the rate of recanalization is high for coronary embolism from myxomas, and it also helps to detect concomitant CAD. [14],[15],[16]

The immediate surgical removal of atrial myxoma should be planned after diagnosis, as the probability of thromboembolic complications increases in the course of time. Excision of tumor, arteriotomy, removal of embolus, and CABG should be done to restore distal blood flow in coronary artery if there is obstruction. [2]

 Conclusion



Though atrial myxomas are rare, the current case suggests that similar situations are bound to arise again in the future. The present case justifies that atrial myxomas should also be considered in the differential diagnoses of acute MI when dealing particularly with young patients, without cardiovascular risk factors, so that a timely intervention could be carried out to prevent any catastrophe.

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