An enormous right atrial myxoma highlights the role of echocardiography in heart failure pathways: a case report

Abstract

Background: Myxomata are rare, benign, primary tumours of the heart which can present with a variety of symptoms depending on size, location, and mobility. Here, we report a case of enormous right atrial myxoma, obliterating the right atrial and right ventricular cavities presenting with symptoms of heart failure.

Case summary: A 66-year-old Caucasian female presented to primary care with symptoms of right heart failure and was found to have elevated N-terminal pro B-type natriuretic peptide of 2829 ng/L (normal value <125 ng/L). The patient was referred for urgent evaluation to the integrated heart failure service at our institution. Echocardiography revealed an enormous mobile mass attached to the right atrial septum, extending into the right ventricle and inferior vena cava measuring 90 × 42 mm. The patient underwent urgent surgical resection. Perioperative transoesophageal echocardiography demonstrated severe tricuspid regurgitation, which was treated with tricuspid annuloplasty ring. The patient made an uneventful recovery and was discharged. Subsequent imaging showed a reduction in right ventricular dimensions and improved systolic function.

Discussion: This case serves to remind us of the critical role of echocardiography in the diagnosis and management of people with breathlessness and raised natriuretic peptides. Therapies for heart failure are guided by ejection fraction, therefore timely and accurate diagnosis is critical. Moreover, as in this case, echocardiography can also identify other features of critical relevance to patient care.

Keywords: Cardiac tumour; Case report; Myxoma; Tricuspid regurgitation.

Figure 1

(A) Modified four-chamber transthoracic echocardiogram. (B) Short-axis transoesophageal echocardiogram showing a large, mobile mass arising from the right atrium and extending into the right ventricle.

Figure 2

(A) Chest radiograph showing a dilated right atrium and small left pleural effusion and (B) coronal plane computerized tomography of the chest showing right atrial mass obliterating right atrial and right ventricular cavities.

Figure 3

Image of large right atrial mass following (A) atriotomy, (B) resection, and (C) with reference, the mass had formed a cast of the right heart, with an indent at the level of the tricuspid annulus.

Figure 4

(A) Two-dimensional transoesophageal echocardiography following resection showing annular dilatation and severe tricuspid regurgitation and (B) following tricuspid annuloplasty showing reduction in annular dimensions and (C) mild tricuspid regurgitation on continuous wave doppler.

Figure 5

Histopathology imaging of myxoma following surgical resection showing (A) low power morphology, (B) lipidic cells within myxoid stroma, and (C) glandular elements highlighted by CK7 immunohistochemistry.