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Case 204

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Female patient, 72 years old, previously healthy, seeks hospital care after ischemic stroke of sudden onset confirmed by computed tomography and magnetic resonance imaging of the skull. Laboratory tests and Doppler of the vertebral and carotid arteries were requested, which did not reveal the cause of the stroke. The investigation followed with transesophageal and transthoracic echocardiograms. On physical examination: oriented, afebrile, blood pressure of 120 / 70mmHg, cardiac frequency of 74bpm, regular rhythm, respiratory rate of 14bpm.

Based on the information and the images presented, what is the most likely cause of the stroke?

a) Heart vegetation

25%

b) Atrial myxoma

25%

c) Atrial thrombus

25%

d) Atrial papillary fibroelastoma

25%
   

Image analysis

Image 1: Mass in the left atrium of heterogeneous sonographic appearance (red), with diffuse hypoechoic areas suggestive of hemorrhage or necrosis and hyperechoic brighter points, suggestive of calcification (blue arrow).

 

 

Images 2 and 3: Mass attached to the atrial septum by a pedicle, with wide mobility towards the left ventricle during ventricular diastole, impairing the mitral valve flow.

Highlights

- Myxomas represent the majority of the primary benign tumors of the heart and are usually located in the left atrium.

- These tumors are related to severe complications and even death, who’s symptons are dependent on the size of the tumor.

- The mass may be an ocasional finding on routine examination or be suspected in presence of multiple embolic processes, prolonged fever and heart murmurs.

- The echocardiogram is the exam of choice for the diagnosis of myxomas, allowing the visualization of a pedicled mass with smooth contours, located near the oval fossa.

- The treatment is surgical resection with high survival rates.

References

- Motta AAR, Colen Filho E, Colen EA, Viera JAS, Alves MAP, Borges MF, et al. Mixoma do átrio esquerdo: relato de 3 casos. Revista Brasileira  de Cirurgia Cardiovascular. 1997; 12(4):377-83.

- Motta AAR, Colen Filho E, Borges MF, Colen EA. Cirurgia cardíaca de emergência para ressecção de mixoma atrial esquerdo. Revista Brasileira de Cirurgia Cardiovascular. 2008;  23( 2 ): 283-287.

- Barbuto C, Sueth DM, Pena FM, Vieira MA, Franklin MM, Teixeira MA. Mixoma Atrial Esquerdo. Revista da SOCERJ. 2006; 19 (2): 180-183.

- Salgado A, Reis C, Silva V, Castier M. Papel da Ecocardiografia na Avaliação dos Tumores Cardíacos e de Massas Cardíacas não Infecciosas. Revista Brasileira de Cardiologia. 2012; 5(3):230-240

- Brant LCC, Mitu O, Gomide L, Bráulio R, Nunes MCP. Large Atrial Myxoma Causing Mitral Obstruction and Severe Pulmonary Hypertension. 2011.

- Camarozano A, Rabischoffsky A, Maciel BC, Brindeiro Filho D, Horowitz ES, Pena JLB, et al. Sociedade Brasileira de Cardiologia. Diretrizes das indicações da ecocardiografia. Arq Bras Cardiol.2009;93(6 supl.3):e265-e302.

Authors

Débora Faria Nogueira, 5th year medical student at UFMG.

E-mail: deborafarianog[at]gmail.com

 

Luísa Bernardino Valério, 4th year medical student UFMG.

E-mail: luisabernardino[at]gmail.com 

Supervisor

Dr. Cristiane Duarte, Cardiologist, doctor at Hospital Risoleta Torentino Neves.

E-mail: cristianeduarte2000[at]yahoo.com.br

Acknowlodgment

To Dr. Maria Cristina Costa de Almeida, cardiologist, and to the ecocardiography team of the Hospital Vera Cruz for supplying the images, availability and support.

Reviewers 

André Guimarães, Hércules Riane, Júlia Petrocchi and prof. Viviane Parisotto. 

Translated by

Bárbara de Queiroz e Bragaglia, 6th year medical student at UFMG.

E-mail: barbara.bragaglia[at]ufmg.br

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