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Cardiac surgery for a right atrial myxoma with traumatic intracranial hemorrhage: a case report | Journal of Cardiothoracic Surgery

An 82-year-old woman was hospitalized at our emergency center due to a head injury after syncope. She was on anticoagulant therapy due to a previous cerebral infarction. Upon arrival at the emergency medical center, her consciousness was clear, and other vital signs were also stable (heart rate, 74 bpm/min; blood pressure, 109/45 mmHg; respiratory rate, 22 breaths/min; oxygen saturation, 95% [room air]). Signs of a head injury were only found on physical examination. The laboratory data were almost normal except for C-reactive protein (7.91 mg/dL), platelets (9.9 × 104L), D-dimer (234 μg/ml), and activated partial thromboplastin time (APTT) (42.5 s). Electrocardiogram showed regular sinus rhythm. Brain computed tomography (CT) revealed traumatic subarachnoid hemorrhage (SAH) and subdural hemorrhage (Fig. 1a). Full body enhanced CT revealed a large defect in the right atrium (Fig. 2) and a small deep venous thrombus, but no pulmonary embolism. Neither mass lesions nor enlarged lymph nodes were observed on enhanced CT. Consequently, we performed transthoracic echocardiography (TTE), which showed a large, highly echogenic, mobile mass in the right atrium (55 × 45 mm) connected to the anterior free wall and prolapsing through the tricuspid valve into the right ventricle during diastole. Doppler echocardiography revealed a peak pressure gradient of 36 mmHg between the right atrium and ventricle. Color Doppler revealed a moderate tricuspid valve regurgitation (TR), moderate mitral valve regurgitation, and moderate aortic valve regurgitation. The tumor seemed attached to the tricuspid valve, and we could not measure it. The wall motion of the left ventricle was normal, no asynergy was observed, and ejection fraction was 66%. The wall motion of the right ventricle was also normal (Tricuspid annular plane systolic excursion, 20 mm; Systolic tricuspid annulus migration velocity, 11 cm/s). As the tumor could be a thrombus, she was started on unfractionated heparin 10000U per day (body weight 42 kg), and APTT was controlled at > 55 s. The following day, the D-dimer level had decreased to 47.5 μg/ml, but the size of the tumor remained unchanged. Based on the above, we established the diagnosis of a right atrial myxoma with intracranial hemorrhage. Her vital signs were stable, and due to cerebral hemorrhage, immediate surgical excision of the right atrial mass could not be performed. We reperformed physical examination, TTE, laboratory tests, and brain CT several times following her admission. The waiting period was uneventful. On the 15th day, brain CT showed no signs of SAH and only a slight subdural hemorrhage (Fig. 1b). On the 18th day, cardiac surgery with cardiopulmonary bypass (CPB) was performed. Transesophageal echocardiography (TEE) confirmed the TTE finding (Fig. 3a and b). The myxoma appeared as if it had broken into pieces and had been embolized to the pulmonary arteries.

Fig. 1
figure 1

a Brain computed tomography (CT) on admission showing subarachnoid and subdural hemorrhages (arrows). b Repeat brain CT showing the disappearance of the subdural hemorrhage

Fig. 2
figure 2

Enhanced computed tomography revealing a large defect in the right atrium (arrows). a Coronal view. b Axial view

Fig. 3
figure 3

a Transesophageal echocardiography showing a large mass with heterogeneous echogenicity. b The mass passed through the tricuspid valve to the right ventricle in the diastolic phase

The surgical approach involved a median sternotomy. CPB was established between the ascending aorta and the supra vena cava (SVC) via the SVC and infra vena cava via the femoral vein. A normal dose of unfractionated heparin (300 units/kg) was administered. During CPB, the activated clotting time was maintained at approximately 400 s. The right atrium was opened, and a large red mass was found attached to the anterior wall of the atrium. The mass was excised and was found to comprise two parts: a small mass that ran along the atrial wall to which the tumor stalk was attached (Fig. 4a) and a large detached mass (Fig. 4b). The defect was repaired using an autologous pericardial patch. The tricuspid valve leaflets and subvalvular apparatus seemed normal. Tricuspid annuloplasty was performed using a 30-mm tricuspid annuloplasty ring (Physio Tricuspid annuloplasty ring; Edwards Lifesciences Co., Tokyo, Japan) because TEE showed moderate TR and the tricuspid annulus was dilatated. CPB was slowly discontinued with pacing. The surgery was uneventful.

Fig. 4
figure 4

a One part of the excised tumor comprising a 25 × 15 × 15 mm mass and a 12 × 11 × 6 mm section of the right atrial wall. b The other part comprising a 92 × 50 × 30 mm mass. c The chromatin histology sections cut between the solid and dotted lines in (b) showing spindle-shaped and star-shaped cells

The giant mass (92 × 50 × 30 mm) was rough and covered in a gelatinous substance. Histopathological examination showed typical myxoma cells interspersed in the mucus matrix (Fig. 4c).

On the 1st postoperative day, the patient was extubated. The brain CT showed no hemorrhage 24 days post-operation. Her consciousness was fine, but physical activity was reduced; thus, she was transferred to a rehabilitation hospital on the 32th day after brain CT, and there were no signs of hemorrhage and infarction.

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