CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 272 AFRICA Discussion PE is associated with various haemodynamic effects ranging from asymptomatic to life-threatening conditions from obstruction to the pulmonary vasculature.3 Pulmonary angiography is a good approach for diagnosis or exclusion of PE. The method has a sensitivity of 98% and a specificity of 95 to 98%. However, due to its invasiveness, most of the major centres in the world do not perform it much anymore. CTPA is currently the first-line approach for diagnosis of PE. CTPA has a sensitivity of 83% and a specificity of 96%. Notably, the sensitivity can be improved from 83 to 90% by combination of CTPA and CT venography, while maintaining the same specificity. Echocardiography is important for the diagnosis of a suspected PE and for excluding other cardiovascular diseases. Moreover, echocardiography is widely used for risk stratification of acute PE. However, the sensitivity of echocardiography is approximately 60 to 70% and negative results do not indicate the absence of PE. TEE is used for diagnosis of some haemodynamically significant PE with bilateral central pulmonary thromboembolism. TTE can accurately identify right heart thrombus in four to 18% of patients with acute PE, therefore it can be used to guide treatment of these patients.4 Anticoagulant therapy was administered to the patient in our study after diagnosis of PE using CTPA and on the basis of the patient’s symptoms. However, TTE results showed a mass in the right atrium that affected the patient’s heart function. These findings indicated that the PE had originated from the right atrium and it required surgical resection. Surgical removal of a RAM with PE is the first-line treatment and is characterised by high curative rates.5,6 Myxoma accounts for 50% of all benign heart tumours in adults. Approximately 75% of myxomas occur in the left atrium, 10 to 20% are reported in the right atrium, whereas the rest occur in the left and right ventricles in equal proportitions.1 RAM blocks the tricuspid valve, thus causing elevated venous pressure and tricuspid valve stenosis, ultimately resulting in right heart failure.7 Embolism is mainly associated with the left heart system, and myxoma in the right side can block the pulmonary artery, causing pulmonary hypertension and death in some cases.8 TEE and TTE methods are characterised by 100% sensitivity and are the most commonly used diagnostic methods for detection and preliminary characterisation of atrial myxoma.9 TEE is used for detection of tumours with sizes up to 1–3 mm and, compared with TTE, is more effective in the examination of the posterior of the left atrium, the atrial septum and the right atrium.10 Conclusion A differential diagnosis should be done to explore the cause of PE, and a myxoma should be considered a possible cause of PE. RAM associated with PE should be diagnosed timeously and surgically removed to avoid pulmonary complications and alleviate the clinical symptoms associated with it. References 1. Van Gelder HM, O’Brien DJ, Staples ED, Alexander JA. Familial cardiac myxoma. Ann Thorac Surg 1992; 53: 419–424. 2. Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Medicine (Baltimore) 2001; 80: 159–172. 3. Rali PM, Criner GJ. Submassive pulmonary embolism. Am J Respir Crit Care Med 2018; 198: 588–598. 4. Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, et al. ESC Committee for Practice Guidelines (CPG). Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008; 29: 2276–2315. 5. Gu S, Liu Y, Yan J, Zhang X, Gao J, Xin Y, et al. Surgical treatment of right atrial myxoma and pulmonary embolism. Chin Med J (Engl) 2014; 127: 187–188. 6. Aydın C, Taşal A, Ay Y, Vatankulu MA, Inan B, Bacaksız A. A giant right atrial villous myxoma with simultaneous pulmonary embolism. Int J Surg Case Rep 2014; 5: 206–208. 7. Bulkley BH, Hutchins GM. Atrial myxomas: a fifty-year review. Am Heart J 1979; 97: 639–643. 8. Attar S, Lee YC, Singleton R, Scherlis L, David R, McLaughlin JS. Cardiac myxoma. Ann Thorac Surg 1980; 29: 397–405. 9. Idir M, Oysel N, Guibaud JP, Labouyrie E, Roudaut R. Fragmentation of a right atrial myxoma presenting as a pulmonary embolism. J Am Soc Echocardiogr 2000; 13: 61–63. 10. Fabijanić D, Giunio L, Vujicić M, Vuković I, Ermacora R, Knezević N. Right atrial pacemaker lead thrombosis incidentally detected by transesophageal echocardiography. Coll Antropol 2005; 29: 159–161.
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