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Cardiovascular Disease |

Successful Thrombolysis and Excision of Left Atrial Myxoma Presenting With Weakness

Fahad Alsindi*, MD; Vijay Duggirala, MD; Andrew Villanueva, MD
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Lahey Clinic, Burlington, MA


Chest. 2012;142(4_MeetingAbstracts):122A. doi:10.1378/chest.1389312
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Abstract

SESSION TYPE: Cardiovascular Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: We describe a case of an asymptomatic young female who presents with hemiplegic stroke with successful thrombolysis and left atrial myxoma resection.

CASE PRESENTATION: A 49-year-old female presents to the emergency department with new onset left sided weakness, slurred speech, and left facial droop. She denied any constitutional symptoms. She was hemodynamically stable. Neurological examination revealed left hemiplegic weakness. Her examination was otherwise benign. Her EKG and laboratory tests were unremarkable. CT scan of the brain was normal. Tissue plasminosgen activator (t-PA) was administered and the patient was admitted to the intensive care unit. MRI of the brain showed an acute infarction involving the right frontal, temporal lobe, and basal ganglia. Transesophageal echocardiogram showed a large mobile mass in the left atrium measuring 4.5 cm x 3.8 cm, fixed to the atrial septum by a stalk located superior to the mitral annulus (Fig.1). Surgical resection was performed (Fig.2), revealing a mass with a smooth grey, brown surface suggestive of atrial myxoma. Histopathology was confirmatory showing characteristic polygonal and stellar tumor cells.

DISCUSSION: Atrial myxoma is the most common benign tumor of the heart and has a greater predilection to the left atrium.1 Embolic phenomena is thought to be caused by either tumor detachment or clot embolization.1 Patients can present with dyspnea on exertion, palpitations, or congestive heart failure. Autoimmune features include: constitutional symptoms, fatigue, fever, myalgia, arthalgia, muscle weakness, rash, and weight loss. Activation of pro-inflammatory cytokines such as: IL-6 and Tumor Necrosis Factor alpha (TNFa) have been implicated.2 Often thrombolysis is given to patients presenting with stroke prior to diagnosing atrial myxoma. Although, randomized clinical data is lacking, managing this challenging scenario has resulted in variable results including: clinical improvement, persistent neurological deficits, or death.3

CONCLUSIONS: This case describes an uncommon presentation of stroke in a young patient with left atrial myxoma. Her course resulted in successful clinical outcomes following thrombolysis and surgical resection. Echocardiography should be considered when entertaining sources of thrombo-emboli presenting with stroke.

1) Reynen, K. (1995). “Cardiac myxomas.” N Engl J Med 333(24): 1610-1617.

2) Mendoza, C. E., M. F. Rosado, et al. (2001). "The role of interleukin-6 in cases of cardiac myxoma. Clinical features, immunologic abnormalities, and a possible role in recurrence." Tex Heart Inst J 28(1): 3-7.

3) Nagy, C. D., M. Levy, et al. (2009). “Safe and effective intravenous thrombolysis for acute ischemic stroke caused by left atrial myxoma.” J Stroke Cerebrovasc Dis 18(5): 398-402.

DISCLOSURE: The following authors have nothing to disclose: Fahad Alsindi, Vijay Duggirala, Andrew Villanueva

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Lahey Clinic, Burlington, MA

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