Advertisement

Large Mass in the Left Atrium: The Usual Myxoma or Another Common Etiology?

Published:August 19, 2022DOI:https://doi.org/10.1053/j.jvca.2022.08.012
      A 64-YEAR-OLD, 82-kg, 183-cm man with heart failure with reduced ejection fraction and a remote history of coronary artery bypass graft surgery, mitral valve replacement, left atrial appendage ligation, and chronic atrial fibrillation treated with warfarin presented to the authors’ institution with worsening dyspnea on exertion, fatigue, and orthopnea. He denied chest pain, fever, chills, and palpitations. The physical examination revealed tachycardia and bilateral pitting edema in the lower extremities. A laboratory analysis was notable for markedly elevated N-terminal pro-B-type natriuretic peptide (31,000 pg/mL, normal range <125 pg/mL). The international normalized ratio was increased (1.9). Transthoracic and transesophageal echocardiography (TEE) examinations were performed as part of the diagnostic evaluation, and the images were obtained (Fig. 1, 2, 3; Videos 1, 2, 3). What was the diagnosis?
      Fig 1
      Fig 1Midesophageal 5-chamber transesophageal echocardiography view.
      Fig 2
      Fig 2Midesophageal bicaval transesophageal echocardiography view.
      Fig 3
      Fig 3Apical 4-chamber transthoracic view; the red arrows demonstrate tracts from the pulmonary veins to the mitral valve.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Chen J
        • Strauss B
        • Liang L
        • et al.
        Animal model of left atrial thrombus in congestive heart failure in rats.
        Am J Physiol Heart Circ Physiol. 2019; 317: H63-H72
        • Liao Y
        • Guan M
        • Liang D
        • et al.
        Differences in pathological composition among large artery occlusion cerebral thrombi, valvular heart disease atrial thrombi and carotid endarterectomy plaques.
        Front Neurol. 2020; 11: 811
        • Jennings JM
        • Ideker RE.
        Why do thrombi form in the left but not the right atrium in atrial fibrillation: Differences in platelet P-selectin levels?.
        Heart Rhythm. 2010; 7: 1184-1185
        • Heppell RM
        • Berkin KE
        • McLenachan JM
        • et al.
        Haemostatic and haemodynamic abnormalities associated with left atrial thrombosis in non-rheumatic atrial fibrillation.
        Heart. 1997; 77: 407-411
        • Willoughby SR
        • Roberts-Thomson RL
        • Lim HS
        • et al.
        Atrial platelet reactivity in patients with atrial fibrillation.
        Heart Rhythm. 2010; 7: 1178-1183
        • Hesse B
        • Murphy RT
        • Myles J
        • et al.
        Images in cardiovascular medicine. A left atrial appendage thrombus mimicking atrial myxoma.
        Circulation. 2006; 113: e456-e457
        • Heitner JF
        • Klem I
        • Alexander K
        • et al.
        The case of the disappearing myxoma.
        J Cardiovasc Magn Reson. 2005; 7: 841-843
        • Mahmoud O
        • Haynos W
        • Rollor J.
        Left atrial thrombi masquerading as myxomas: Mini case series and literature review.
        CASE (Phila). 2020; 4: 252-259
        • Faggiano P
        • Dinatolo E
        • Moreo A
        • et al.
        Prevalence and rate of resolution of left atrial thrombus in patients with non-valvular atrial fibrillation: A two-center retrospective real-world study.
        J Clin Med. 2022; 11: 1520
        • Fukuda S
        • Watanabe H
        • Shimada K
        • et al.
        Left atrial thrombus and prognosis after anticoagulation therapy in patients with atrial fibrillation.
        J Cardiol. 2011; 58: 266-277
        • Lakshminarayan K
        • Solid CA
        • Collins AJ
        • et al.
        Atrial fibrillation and stroke in the general medicare population: A 10-year perspective (1992 to 2002).
        Stroke. 2006; 37: 1969-1974
        • Hart RG
        • Pearce LA
        • Aguilar MI.
        Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.
        Ann Intern Med. 2007; 146: 857-867
        • Pappachan JM
        • Bino BC.
        Imaging in clinical medicine. Calcified left atrial thrombus.
        N Engl J Med. 2007; 356: e9
        • Czaplicki C
        • Albadawi H
        • Partovi S
        • et al.
        Can thrombus age guide thrombolytic therapy?.
        Cardiovasc Diagn Ther. 2017; 7: S186-S196
        • Wysokinski WE
        • Owen WG
        • Fass DN
        • et al.
        Atrial fibrillation and thrombosis: Immunohistochemical differences between in situ and embolized thrombi.
        J Thromb Haemost. 2004; 2: 1637-1644
        • Lakkireddy D
        • Vallakati A
        • Kanmanthareddy A
        • et al.
        Left atrial thrombus formation after successful left atrial appendage ligation: Case series from a nationwide survey.
        J Am Coll Cardiol. 2015; 65: 1595-1596
        • Lin AH
        • Oakley LS
        • Krause DJ
        • et al.
        Left atrial thrombus in a patient with left atrial appendage ligation.
        BMJ Case Rep. 2013; 2013bcr2012008342
        • Donnino R
        • Tunick PA
        • Kronzon I.
        Left atrial appendage thrombus outside of a “successful” ligation.
        Eur J Echocardiogr. 2008; 9: 397-398