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Sumario Vol. 42 - Nº 1 Enero - Marzo 2013

Ventricular myxoma in young woman with recurrent stroke.

Adrian H. D'Ovidio, Ana Paola Courtade, Jorge Giron Valverde, Alejandro Coto Sánchez, Darío Benítez, Ramón Caballero.

Hospital Dr. Guillermo Rawson, Centro Integral de Medicina de Alta Complejidad (CIMAC),
Hospital Privado del Colegio Médico. San Juan, Argentina.
Casa 21. Manzana 34. Barrio Altos de Natania.
(5400) Rivadavia. San Juan, Argentina.
(0264) 4332838 – 154036652.
E Mail

Recibido 21-OCT-2013 – ACEPTADO después de revisión el 17-ENERO-2013.

The authors declare not having conflicts of interest.


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SUMMARY

We report the case of a young woman with a recurrent stroke with right faciobraquiocrural hemiparesis and absence of left carotid pulse. The carotid Doppler showed complete occlusion of the left internal carotid artery. Transthoracic Doppler echocardiogram showed the presence of an heterogeneous mobile mass attached to the left ventricular apex occupying almost the entire cavity, protruding into the left ventricular outflow tract and the ascending aorta. The surgeons were unable to resect the big mass trough the left atrial approach so they performed a left apicosthomy. The mass was successfully removed, and pathology confirmed that it was a myxoma. Up today, the clinical follow up was favorable with minimal neurological sequelae.

Key words: Stroke. Mobile mass. Myxoma.
Rev Fed Arg Cardiol. 2013; 42(1): 58-60

 

 

CLINICAL CASE
Woman of 22 years of age, with no cardiovascular risk factors, with history of transient ischemic attack in year 2007 when she was 18 years old, without sequels. She consulted this time because of right brachio-crural hemiparesis and dysarthria of sudden onset. Lucid, oriented in time and space, with no fever. In the cardiovascular examination, regular radial pulse was verified, equal, wide with 80 beats per minute; left carotid pulse with reduced amplitude, the rest of the central and peripheral pulses with equal characteristics to the radial one. Blood pressure 110/70 mmHg. Cardiac auscultation: normal sounding S1 in all areas, muffled S2 with physiological splitting. S3 and S4 are not auscultated. Soft ejection protomesosystolic murmur, 3/6, in aortic area and Erb’s point focus irradiating to the suprasternal notch. Neurological examination: right brachio-crural hemiparesis and dysarthria. Normal routine lab and normal ECG.

Two-dimensional transthoracic echo, in left parasternal long axis view, displaying heterogeneous left intraventricular mass, very mobile, of a large size, friable, holding almost all of the cavity, with vacuolated aspect, which deforms during the cardiac cycle, and which protrudes into the outflow tract and through the aortic valve, with mitral and aortic valves with normal echocardiographic aspect. In this projection, there is no anchoring point visible (Figures 1 and 2).

Figure 1. Parasternal long axis view that shows the left intraventricular mass that occupies almost all the cavity, and that protrudes into the LV outflow tract.
 

Figure 2. Parasternal long axis view that located in the left ventricular outflow tract that shows the protrusion of the mobile mass.

The parasternal short axis view at the level of the papillary muscles (Figure 3) and ofthe great vessels shows the mass protruding through the LV outflow tract and the aortic valve (Video).

Figure 3. Parasternal short axis view at the level of the papillary muscles that shows the intraventricular mass.

The Doppler echo of the neck vessels shows homogeneous hypoechogenic image, without hyperreflectivity in the proximal territory of the left internal carotid artery, completely occluded. The rest of the neck vessels presented diameters and laminar flow with normal systo-diastolic velocity.

The pericardium is open by median sternotomy, proceeding to the ascending aorta and both venaecavae cannulation, with aortic clamping and heparinization, previous connection to extracorporeal circulation. Under myocardial protection with crystalloid cardioplegia, cardiac arrest is conducted and from the left atrium we entered the left ventricle through the mitral valve. Before a tumor strongly adhered to the left ventricular apex, which cannot be extracted through this via, left ventriculotomy is made by apicostomy (Figure 4) that allows releasing the tumor from the adhesions to the endocardium for its resection (Figure 5). Later the cavity is washed, the left ventriculotomy is closed with teflon patch reinforcement and incision in the left atrium. Finally, the cavities are cleansed, extracorporeal circulation is left and the sternotomy is sutured.

Figure 4. Left ventriculotomy by apicostomy.

 

Figure 5. Tumor released from adhesions for its resection.

The anatomopathological study confirms the diagnosis of myxoma.

The patient evolves favorably, asymptomatic, without immediate or late postoperative complications, with gradual recovery of motricity and minimal dysarthria. In the postoperative evolution, the two-dimensional echocardiographic, M mode and Doppler recordingsare within normal limits.

 

DISCUSSION
The presence of tumors in the LV is very infrequent and myxomas are even less frequent. Thrombi, endocavitary vegetations, fibromas, and metastatic tumors such as mammal and bronchogenic carcinoma are much more frequent [1,2,3].

Secondary [4,5] or metastatic cardiac tumors, from which the most frequent one is bronchogenic carcinoma, are 20 to 40 times more common than primary ones, from which myxoma is the most frequent (30-50%) [1].

Myxomas are quite more frequent in women (65%), with atypical signs and symptoms and familial presentation in 4.5-10% of the cases. Predominantly, its location is in the left atrium (75-86%) and the right atrium (7.4-15%).

For their great emboligenic potential, they have to be surgically resected [6].

In this clinical case, the following are outstanding: the size of the tumor that occupied more than 80% of the left ventricular chamber without causing a significant obstruction of the LV outflow tract, except intermittently, and the late diagnostic finding in relation to the age of the patient.

 

 

rEFERENCES
  1. Armstrong W. & Ryan T. Masses, tumors and source of embolus. En Feigenbaum`s Echocardiography. Wolters Kluver / Lippincott / Williams & Wilkins. USA. 7th Edition 2010; Ch.23: 711-740.
  2. Colucci WS, Schoen FJ. Primary tumors of the heart. In Braunwald, Zipes, Libby. Heart Disease. 6th Edition 2001. W.B.Saunders & Co; Philadelphia, Pensylvania, USA. Ch.49: 1807-1822.
  3. Mc Manus B & Lee CH-H. Primary tumors of the heart. Braunwald`s Heart Disease. W.B.Saunders Elsevier, 8th Edition 2008; Ch.69: 1815-1828.
  4. Oh JK, Seward JB, Tajik AJ. Tumors and Masses. The Echo Manual. Lippincott / Williams & Wilkins. USA. 3rd Edition 2007; Ch.18: 311-321.
  5. Calvo F, Zamorano JL. En Procedimientos en Ecocardiografía. Miocardiopatías. McGraw-Hill-Interamericana 2003; Cap.9: 243-256.
  6. McManus Bruce. Primary tumors of the heart. Braunwald’s Heart Diseases. 9th Edtiion 2012; Ch.74: 1638-1650.

 

 

Publication: March 2013

 
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