CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 270 AFRICA Case Reports Fire at the gate ruins fish: pulmonary embolism caused by right atrial myxoma Kang He, Longrong Bian, Weitao Liang, Zhong Wu Abstract Myxoma is the most common benign type of cardiac tumour. Myxomas mainly occur in the left atrium, rarely in the right atrium. Right atrial myxoma (RAM) is therefore associated with few cases of pulmonary embolism (PE). In this study, we explored a case of RAM associated with PE and characterised by loss of consciousness. The patient was treated by surgical excision of the RAM. After the surgery, the patient showed a good recovery and was discharged nine days after the operation. Keywords: right atrial myxoma, pulmonary embolism, surgical Submitted 2/7/21, accepted 7/12/21 Published online 1/7/22 Cardiovasc J Afr 2022; 33: 270–272 www.cvja.co.za DOI: 10.5830/CVJA-2021-062 Approximately 75% of myxoma cases occur in the left atrium and 10 to 20% in the right atrium.1 Pulmonary embolism (PE), caused by right atrial myxoma (RAM), can lead to pulmonary hypertension and death as a result of acute embolism.2 Therefore, surgical resection is required for effective treatment of the myxoma. Case report A 56-year-old male patient was referred to our institution from a primary healthcare centre where he had been diagnosed with PE. He received anticoagulation therapy after presenting with palpitations and loss of consciousness for a month. After admission, the patient underwent computed tomography pulmonary angiography (CTPA) and the results showed that he had PE, mainly affecting the trunk of the right pulmonary artery (Fig. 1B) and some branches of the left lung. The findings initially indicated the presence of thrombo-embolism, therefore, routine anticoagulation therapy was administered. However, transthoracic echocardiogram (TTE), performed on the second day after admission, showed the presence of a 16 × 22-mm mass attached to the wall of the right atrium with clear margins and intense activity (Fig. 1A). Notably, the mass did not extend to the superior and inferior vena cavae, and the tricuspid valve orifice. Examination of the patient did not the show the presence of pulmonary hypertension or failure of the right ventricle. Results from colour Doppler ultrasound examination of the veins of the lower extremities indicated that the patient had no venous thrombosis. To exclude potential surgical risk factors, laboratory tests were performed and the results were as follows: erythrocyte sedimentation rate: 119 mm/h, C-reactive protein level: 88.90 mg/l; and international normalised ratio: 1.19. The antithrombin III, protein C and protein S activities were normal. Levels of natriuretic peptide and myocardial markers were normal; antiphospholipid antibodies were all negative; liver, kidney and thyroid function were normal. The patient was therefore scheduled for surgery. The operation was performed through a median sternotomy with cannulation of the aorta, and superior and inferior vena cavae. The superior and inferior vena cavae were encircled with umbilical tape and snared to isolate the right atrium, where after it was opened. A soft, pedunculated mass was removed from the right atrial pectinate muscle (Fig. 2A, B). To prevent detachment of the mass and intra-operative embolisation, we minimised movement and compression of the heart and a gauze was placed at the tricuspid orifice during surgery. The inter-atrial septum where the myxoma pedicle was attached was resected completely, which can prevent recurrence. The right atrium incision was closed and the aorta was cross-clamped to arrest the heart, using blood cardioplegia. The main left and right pulmonary artery were then opened sequentially (Fig. 2C, D). The left embolus was not close to the incision therefore the embolism was removed under deep hypothermic (20°C) and intermittent circulatory arrest to keep the surgical field clean. The patient showed a good recovery without any adverse events and was discharged from hospital nine days after the surgery. Follow up was conducted after discharge. Results from the postoperative histopathological examination showed that the embolism and mass from the right atrium was a myxoma. Transoesophageal echocardiography (TEE) was conducted three months after the surgery and the results showed that the heart function of the patient was fully restored. The patient did not present with pulmonary hypertension. Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China Kang He, MS Longrong Bian, MS Weitao Liang, MD Zhong Wu, MD, wuzhong71@scu.edu.cn
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