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Hemoptysis in Pregnancy as the First Sign of Left Atrial Myxoma FREE TO VIEW

Pooja Kanth, MD; Tuong Vu, MD; Feroza Daroowalla, MD
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SUNY at Stony Brook University School of Medicine, Department of Internal Medicine, Stony Brook, NY

Chest. 2014;146(4_MeetingAbstracts):200A. doi:10.1378/chest.1991271
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SESSION TITLE: Miscellaneous Student/Resident Cases

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 04:30 PM - 05:30 PM

INTRODUCTION: Atrial myxoma is a rare benign primary cardiac tumor found mostly in females between ages 30 and 60. Dyspnea on exertion is the presenting symptom of left atrial myxoma, occurring with tumor size (3-6cm).1 Neurologic embolism can occur as a complication in 10%. Right atrial myxomas present with hemoptysis after embolism to the pulmonary arteries.

CASE PRESENTATION: We describe a 25 year old pregnant female, G3P2, gestational age 28 weeks, with no significant history, who presented with three episodes of hemoptysis in one week. Prior to the initial episode, she was treated for dyspnea and cough with a course of antibiotics and steroids. Exam now revealed dried blood in the oropharynx and normal cardiopulmonary exam. Chest x-ray showed mild bilateral pulmonary congestion but no focal parenchymal abnormalities. Transthoracic echocardiogram revealed a left atrial mass measuring 4.85cm x 3.38cm (Image 1). Left atrial size was increased (volume 84mL, area 28.2cm2, diameter 5.00cm). The mass caused flow obstruction of the mitral valve resulting in a hemodynamic picture similar to that of mitral stenosis. Tricuspid regurgitation was insignificant. A multidisciplinary meeting to discuss best management for mother and fetus resulted in plans to proceed to immediate surgery. Due to concerns for venous thromboembolism and poor tolerance of severe mitral stenosis at delivery, immediate excision was preferred. Anticoagulation was not felt to decrease the risk of embolization. The patient underwent mass resection the next day using a reduced pump time approach; histopathology confirmed myxoma. She tolerated the rest of her pregnancy without complication.

DISCUSSION: Hemoptysis is a known presentation of right atrial myxoma, however there are few reports of hemoptysis from left atrial myxoma. In our patient, advanced pregnancy was key in revealing her myxoma. By the third trimester of pregnancy, intravascular volume increases by roughly 50%.2 This increased load on the left heart exaggerates the degree of mitral valve pseudo-stenosis from a moderate-sized tumor, resulting in increased pulmonary pressures causing hemoptysis. Had our patient not been pregnant, the moderate-sized myxoma may have gone undiagnosed for years, with an increasing clot burden surrounding the mass, elevating her risk of embolism from both clot and tumor (Image 2).

CONCLUSIONS: Large left atrial myxoma can mimic mitral stenosis, and late complications include hemoptysis. With the intravascular volume increase accompanying pregnancy, our patient presented with symptoms despite the moderate size of her mass. Early removal reduces the risk of embolism and heart failure secondary to mitral stenosis.

Reference #1: Percell, R. L., Jr., R. J. Henning, and Siddique Patel. "Atrial Myxoma: Case Report and a Review of the Literature." Heart Disease 5.3 (2003): 224-30.

Reference #2: Vincent, Robert D. "Anesthesia for the Pregnant Patient." Clinical Obstetrics and Gynecology 37.2 (1994): 256-73.

DISCLOSURE: The following authors have nothing to disclose: Pooja Kanth, Tuong Vu, Feroza Daroowalla

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