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CASE REPORT
Giant obstructive left atrial myxoma resembling mitral valve stenosis
Solange Desirée Avakian, Julio Yoshio Takada, Antonio de Padua Mansur
Corresponding author
apmansur@usp.br

Tel.: 55 11 2661-5387
Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo Medical, Heart Institute (InCor), São Paulo/SP, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Primary tumors of the heart are rare&#44; with an incidence between 0&#46;0017&#37; and 0&#46;19&#37; in unselected patients at autopsy&#46; Approximately 75&#37; of the tumors are benign&#44; and nearly half of them are myxomas &#40;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#41; Atrial myxoma is the most common benign cardiac neoplasm&#44; and its origin has been ascribed to a multipotential mesenchymal cell &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#41; Myxomas commonly occur between the third and sixth decades of life and are three times more frequent in women &#40;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#41; There are two distinctive forms of the tumors&#58; solid and ovoid myxomas and soft and papillary myxomas&#46; Solid tumors are more likely to present with symptoms of congestive heart failure &#40;CHF&#41;&#44; while papillary tumors are more likely to embolize to the cerebral and other peripheral vessels &#40;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#41; At the time of diagnosis&#44; 92&#37; of the patients have symptoms of CHF &#40;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#41; Atrial myxoma may mimic valvular heart disease&#44; cardiac insufficiency&#44; cardiomegaly&#44; bacterial endocarditis&#44; disturbances of ventricular and supraventricular rhythm&#44; syncope&#44; and systemic or pulmonary embolism &#40;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#41; The purpose of this paper is to present a case report of atrial myxoma mimicking severe mitral valve stenosis at cardiac auscultation and the importance of echocardiograpy in the diagnosis&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE DESCRIPTION</span><p id="para20" class="elsevierStylePara elsevierViewall">A 77-year-old Caucasian man presented at the Emergency Care Unit with a six-month history of congestive heart failure and in funcional class III&#44; according to the New York Heart Association &#40;NYHA&#41; criteria&#46; He had no previous history of diabetes&#44; arterial hypertension&#44; or ischemic coronary disease&#46; The physical examination disclosed distended neck veins&#44; rales at the lung base&#44; and hepatomegaly&#46; Cardiac auscultation revealed a loud first heart sound and diastolic rumble resembling mitral valve stenosis&#46; Chest radiography showed a normal cardiac silhouette image&#44; enlarged hilar shadows and moderate right-sided pleural effusion&#46; The electrocardiogram showed a regular sinus rhythm with a nonspecific repolarization alteration&#46; The transthoracic echocardiogram showed an image of a large pediculate mass of 5&#46;5 mm&#215;4&#46;0 mm in the left atrium in his greater diameters&#44; restricting transmitral diastolic blood flow&#44; and an atrium-ventricular pressure gradient of 11 mmHg &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#41;&#46; This mass was attached to the inferior edge of the fossa ovalis&#46; Left ventricular function was normal&#44; and the right ventricular diameter was 3&#46;2 cm&#46; His systolic pulmonary artery pressure was 100 mmHg&#46; The patient was referred for cardiac surgery&#46; The adopted technique was a biatrial approach&#46; The intraoperative findings included a mass&#44; and anatomopathologic analysis confirmed that it was an atrial myxoma&#46; Two days after surgery&#44; an echodopplercardiogram showed an important reduction in systolic pulmonary artery pressure to 30 mmHg&#46; Five years later&#44; an echocardiogram showed no mass in the left atrial chamber&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para30" class="elsevierStylePara elsevierViewall">This case report showed an atrial myxoma mimicking mitral valve stenosis&#46; The diagnosis was made by echocardiogram&#44; which disclosed a huge mass obstructing the left atrial blood flow&#46; Heart valve disease is one of the differential diagnoses of atrial myxomas&#46; The clinical findings of cardiac tumors are characterized by the triad of embolism&#44; intracardiac obstruction&#44; and constitutional findings&#46; Congestive heart failure is the most common clinical presentation&#44; followed by neurologic and systemic embolic events&#46; Embolic events more frequently affect the cerebral arteries&#44; including the retinal arteries&#46; Embolization into visceral&#44; renal&#44; or coronary arteries has also been reported and can affect nearly 29&#37; of patients &#40;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#41;&#46; Although the large majority of myxomatous emboli are cerebral&#44; it is possible for atrial myxomas to embolize and implant in other locations in the visceral and peripheral arterial circulation&#46; Ectopic myxoma implants have been described in other unusual locations&#44; including the skin&#44; the skeleton&#44; and the small bowel&#46; Intracardiac obstruction with impaired filling of the left or right ventricle causes subsequent dyspnea&#44; recurrent pulmonary edema&#44; right-heart failure or even syncope or sudden death &#40;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#41;&#46; Three fourths of myxomas are located in the left atrium &#40;<a class="elsevierStyleCrossRef" href="#bib7">7</a>&#41;&#46; General or constitutional manifestations&#44; such as fatigue&#44; fever&#44; weight loss&#44; night sweats&#44; arthralgia&#44; and laboratory abnormalities&#44; such as elevation of C-reactive protein&#44; anemia&#44; and the erythrocyte sedimentation rate&#44; can also occur&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">Mitral valve obstruction caused by atrial myxoma represents an important hemodynamic consequence leading to symptoms of congestive heart failure&#44; pulmonary hypertension&#44; syncope&#44; and sudden death&#46; Clinicopathologic correlations showed that mitral stenotic effects occurred when the tumor diameter exceeded 5 cm &#40;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#41;&#46; Echodopplercardiography is the most important method for the differential diagnosis with primary valve disease&#46; Moreover&#44; it can estimate the transvalve gradient&#46; It has been reported that patients with left atrial myxomas have reduced transmitral blood flow&#46; Nevertheless&#44; only large myxomas can resemble severe mitral stenosis&#46; The differential diagnosis of an intracardiac mass encompasses benign and malignant primary heart tumors&#44; metastatic tumors and thrombi&#46; Eletrocardiographic findings are unspecific&#46; The cardiac rhythm is usually normal&#46; Chest X-ray may reveal an enlargement of the left atrium and some signs of pulmonary hypertension and congestion&#46; Calcifications&#44; which make the tumor visible on routine radiographic examination&#44; are unusual&#46; Computed tomography and magnetic resonance imaging can differentiate tissue composition&#44; making it possible to identify the nature of the mass&#46; The preoperative diagnosis of cardiac tumors could be performed correctly utilizing angiography&#44; echocardiography&#44; or both&#46; Coronary angiography is reserved for older patients who may have coexisting coronary artery disease &#40;<a class="elsevierStyleCrossRef" href="#bib9">9</a>&#41;&#46;</p><p id="para50" class="elsevierStylePara elsevierViewall">Controversy remains regarding the optimal operative approach to atrial myxomas&#46; The biatrial approach has been advocated to achieve the most complete tumor excision and assess the possibility of tumors in the right atrium &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#41;&#46; Other options include minimally invasive thoracoscopic surgery and the use of robotic technology&#46; Surgical excision of the tumor appears to be curative&#44; and recurrence is rare&#44; as shown five years later in an echocardiogram of this patient&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">AUTHOR CONTRIBUTIONS</span><p id="para60" class="elsevierStylePara elsevierViewall">All of the authors participated in manuscript preparation&#44; data collection and data interpretation&#46; All of the authors read and approved the final manuscript&#46;</p></span></span>"
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