International Journal of Cardiology 172 (2014) e165–e166
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Angina pectoris: First manifestation of a left atrial myxoma E. Imbalzano a, G. Di Bella b, M. Casale b, I. Boretti b, R. Manganaro b, A. Lamari c, G. Dattilo b,1 a b c
Department of Internal Medicine, University of Messina, Italy Department of Clinical and Experimental Medicine, University of Messina, Italy U.O. of UTIC and Cardiology, Hospital of Urbino, ASUR 1 Marche, Italy
a r t i c l e
i n f o
Acknowledgments
Article history: Received 1 October 2013 Accepted 22 December 2013 Available online 28 December 2013
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
Keywords: Cardiac Mixoma Transesophageal echocardiography Coronary embolization Primary cardiac tumors
References
Primary cardiac tumors are rare and myxomas are the most common among them. In the majority of cases myxomas have a benign clinical progress, but it's possible for a coronary artery embolization, which is a potentially lethal complication [1–17]. We show the case of a man of 55 years, who underwent to a cardiac check-up because of the presence, from the two past days, of angina pectoris. He suffers from arterial hypertension in pharmacological therapy, diabetes mellitus of recent diagnosis and a past episode of atrial fibrillation [18–28]. The ECG and the hematological tests were normal. Transthoracic echocardiography showed mild regurgitation and mild stenosis of the aortic and mitral valve and a mobile mass attached to the left atrial septum, which was difficult to define for the poor picture quality. Transesophageal echocardiography showed a left atrial mass arising from the atrial septum, compatible with the diagnosis of cardiac myxoma [29–33] (Fig. 1). The patient underwent coronary angiography that showed no major injuries. After that he underwent cardiac surgery to remove the tumor. In the following months, there were no more symptoms of angina pectoris. We hypothesize that the clinical manifestation of angina is due to coronary embolization from the myxoma and not a phenomenon of coronary steal potentially induced by the rich vascularization of the mass. We think that because the patient had only a single, short lasting episode of angina. No presence of coronary emboli is justified that there was a tendency to spontaneous re-channeling of the obstructed coronary vessels, perhaps because of the tumors' tissue composition [14,15,17]. Also this case shows the potential lethality of cardiac myxomas. E-mail address: [email protected] (G. Dattilo). Unità Operativa Complessa di Cardiologia, Azienda Ospedaliera Universitaria “Policlinico G. Martino” Via Consolare Valeria n.1, 98125 Messina, Italy. Tel.: + 39 3474113202. 1
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.059
[1] Moreno Martínez FL, Lagomasino Hidalgo A, Mirabal Rodríguez R, López Bermúdez FH, López Bernal OJ. Recurrent left atrial myxoma. Arch Cardiol Mex 2003;73(4):280–3. [2] Okamoto Y, Shimura K, Mitsumori Y, et al. Recurrent cardiac myxoma that developed rapidly in a short period. Kyobu Geka Feb 2009;62(2):129–32. [3] Santangeli P, Pieroni M, Marzo F, et al. Cardiac myxoma presenting with sensory neuropathy. Int J Cardiol Aug 6 2010;143(1):e14–6. [4] Attar MN, Sharman DC, Al-Najjar Y, Moore RK, Millner RW, Khan SX. A rare case of multiple right heart myxomas. Int J Cardiol May 31 2007;118(2):e66–7. [5] Parissis JT, Zezas S, Sfiras N, Kastellanos S. An atypical left atrial myxoma causing intracavitary pressure gradient and typical diastolic transmitral flow of severe mitral stenosis. Int J Cardiol Jun 22 2005;102(1):165–7. [6] Yazici M, Norgaz T, Akdemir R, Albayrak S. Asymptomatic giant left atrial myxoma supplied from right coronary artery in a 65-year-old woman. Int J Cardiol Jun 8 2005;101(3):495–6. [7] Dattilo G, Lamari A, Messina F, et al. The chance finding at multislice computed tomography coronary angiography of an ectopic origin of the left circumflex coronary artery from the right sinus of Valsalva. Int J Cardiol Jun 2 2011;149(2): e43–6. [8] Dattilo G, Carerj S, Lamari A, et al. The chance finding at multislice computed tomography coronary angiography of myocardial bridging. Int J Cardiol Jan 26 2012;154(2):e21–3. [9] Gogas BD, Rallidis LS, Iliodromitis EK, Kremastinos DT. Right atrial myxoma presenting as syncope due to pulmonary embolism in a previously asymptomatic patient. Int J Cardiol Apr 14 2011;148(2):e34–6. [10] Acikel M, Yekeler I, Ates A, Erkut B. A giant left atrial myxoma: an unusual cause of syncope and cerebral emboli. Int J Cardiol Apr 2004;94(2–3):325–6. [11] Dattilo G, Tulino V, Tulino D, Lamari A, Marte F, Patanè S. Interatrial defect, ventricular septal defect and patent ductus arteriosus in a 2-day-old newborn infant. Int J Cardiol May 15 2009;134(2):e82–3. [12] Patanè S, Marte F, Sturiale M, Dattilo G. ST-segment elevation and diminution of prostate-specific antigen in a patient with coronary spasm and without significant coronary stenoses. Int J Cardiol Apr 14 2011;148(2):e31–3. [13] Patanè S, Marte F, Dattilo G, Sturiale M. Acute myocardial infarction and left bundle branch block with changing axis deviation. Int J Cardiol Feb 9 2012;154(3):e47–9. [14] Braun S, Schrötter H, Reynen K, Schwencke C, Strasser RH. Myocardial infarction as complication of left atrial myxoma. Int J Cardiol May 11 2005;101(1):115–21. [15] Panos A, Kalangos A, Sztajzel J. Left atrial myxoma presenting with myocardial infarction. Case report and review of the literature. Int J Cardiol Oct 31 1997;62(1):73–5. [16] Tulino D, Imbalzano E, Casale M, et al. Treatment failure of low molecular weight heparin in diabetic patient. Int J Cardiol 2013 Sep 30;168(2):e63–4. [17] Milicevic G, Gavranovic Z, Cupic H, et al. Unremitting embolus from cardiac myxoma at circumflex artery trifurcation. Int J Cardiol Jun 6 2008;126(3): 424–6. [18] Alexiou K, Wilbring M, Matschke K. Angina pectoris as first manifestation of a huge biatrial myxoma. Acta Cardiol Oct 2009;64(5):667–8.
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E. Imbalzano et al. / International Journal of Cardiology 172 (2014) e165–e166
Fig. 1. Panel A and B: Transesophageal echocardiography shows a left atrial myxoma arising from the atrial septum. Panel C and Panel D: Coronaric angiography shows absence of coronaric lesions. [19] Kolvekar SK, Keal R, Spyt T. Unusual presentation of an atrial septal aneurysm with left atrial myxoma: a case report. Int J Cardiol Apr 18 1997;59(2):197–8. [20] Tulino V, Cacace C, Tulino D, Imbalzano E, Dattilo G. Clinical variants in Ebstein's anomaly. Int J Cardiol 2013 Oct 12;168(5):4969–70. [21] Mandraffino G, Sardo MA, Riggio S, et al. Circulating progenitor cells are increased in newly diagnosed untreated hypertensive patients with arterial stiffening but normal carotid intima-media thickness. Hypertens Res Jul 2011;34(7):876–83. [22] Mandraffino G, Sardo MA, Riggio S, et al. Smoke exposure and circulating progenitor cells: evidence for modulation of antioxidant enzymes and cell count. Clin Biochem Dec 2010;43(18):1436–42. [23] Sardo MA, Mandraffino G, Campo S, et al. Biglycan expression in hypertensive subjects with normal or increased carotid intima-media wall thickness. Clin Chim Acta Aug 2009;406(1–2):89–93. [24] Dattilo G, Lamari A, Crosca S, et al. Correlation between insulin resistance and endothelial dysfunction assessed by flow-mediated dilation. Recenti Prog Med Sep 2012;103(9):328–32. [25] Sardo MA, Mandraffino G, Riggio S, et al. Effects of the angiotensin II receptor blocker losartan on the monocyte expression of biglycan in hypertensive patients. Clin Exp Pharmacol Physiol Sep 2010;37(9):933–8.
[26] Patanè S, Marte F, Sturiale M, Dattilo G. Changing axis deviation and acute myocardial infarction. Int J Cardiol Aug 18 2011;151(1):e1–3. [27] Patanè S, Marte F, Sturiale M, Dattilo G, Luzza F. Atrial flutter, ventricular tachycardia and changing axis deviation associated with scleroderma. Int J Cardiol Dec 1 2011;153(2):e25–8. [28] Patanè S, Marte F, Dattilo G, Sturiale M. Changing axis deviation during atrial fibrillation. Int J Cardiol Jan 12 2012;154(1):e1–3. [29] Tsai SK. The role of transesophageal echocardiography in clinical use. J Chin Med Assoc 2013 Dec;76(12):661–72. [30] Dattilo G, Lamari A, Tulino V, et al. Congenital valvular heart disease with high familial penetrance. Recenti Prog Med Dec 2012;103(12):581–3. [31] Baglini R. Intracardiac echocardiography in monitoring atrial septal defect percutaneous closure: initial experience in an adult laboratory. Int J Cardiol Jan 8 2007;114(2):274–6. [32] Imbalzano E, Dattilo G, Scarpelli M, Lo Gullo A, Saitta A. Left coronary artery fistula to right ventricle complicated heart failure in a patient on hemodialysis. Intern Emerg Med 2013 Dec;8(8):765–6. [33] Han JH, Shin DH, Lee HJ, et al. Routine preprocedural transesophageal echocardiography might not be necessary for stroke prevention evaluation in AF patients on anticoagulation therapy. Int J Cardiol 2013 Oct 3;168(3):1992–6.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Angina pectoris: First manifestation of a left atrial myxoma E. Imbalzano a, G. Di Bella b, M. Casale b, I. Boretti b, R. Manganaro b, A. Lamari c, G. Dattilo b,1 a b c
Department of Internal Medicine, University of Messina, Italy Department of Clinical and Experimental Medicine, University of Messina, Italy U.O. of UTIC and Cardiology, Hospital of Urbino, ASUR 1 Marche, Italy
a r t i c l e
i n f o
Acknowledgments
Article history: Received 1 October 2013 Accepted 22 December 2013 Available online 28 December 2013
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
Keywords: Cardiac Mixoma Transesophageal echocardiography Coronary embolization Primary cardiac tumors
References
Primary cardiac tumors are rare and myxomas are the most common among them. In the majority of cases myxomas have a benign clinical progress, but it's possible for a coronary artery embolization, which is a potentially lethal complication [1–17]. We show the case of a man of 55 years, who underwent to a cardiac check-up because of the presence, from the two past days, of angina pectoris. He suffers from arterial hypertension in pharmacological therapy, diabetes mellitus of recent diagnosis and a past episode of atrial fibrillation [18–28]. The ECG and the hematological tests were normal. Transthoracic echocardiography showed mild regurgitation and mild stenosis of the aortic and mitral valve and a mobile mass attached to the left atrial septum, which was difficult to define for the poor picture quality. Transesophageal echocardiography showed a left atrial mass arising from the atrial septum, compatible with the diagnosis of cardiac myxoma [29–33] (Fig. 1). The patient underwent coronary angiography that showed no major injuries. After that he underwent cardiac surgery to remove the tumor. In the following months, there were no more symptoms of angina pectoris. We hypothesize that the clinical manifestation of angina is due to coronary embolization from the myxoma and not a phenomenon of coronary steal potentially induced by the rich vascularization of the mass. We think that because the patient had only a single, short lasting episode of angina. No presence of coronary emboli is justified that there was a tendency to spontaneous re-channeling of the obstructed coronary vessels, perhaps because of the tumors' tissue composition [14,15,17]. Also this case shows the potential lethality of cardiac myxomas. E-mail address: [email protected] (G. Dattilo). Unità Operativa Complessa di Cardiologia, Azienda Ospedaliera Universitaria “Policlinico G. Martino” Via Consolare Valeria n.1, 98125 Messina, Italy. Tel.: + 39 3474113202. 1
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.059
[1] Moreno Martínez FL, Lagomasino Hidalgo A, Mirabal Rodríguez R, López Bermúdez FH, López Bernal OJ. Recurrent left atrial myxoma. Arch Cardiol Mex 2003;73(4):280–3. [2] Okamoto Y, Shimura K, Mitsumori Y, et al. Recurrent cardiac myxoma that developed rapidly in a short period. Kyobu Geka Feb 2009;62(2):129–32. [3] Santangeli P, Pieroni M, Marzo F, et al. Cardiac myxoma presenting with sensory neuropathy. Int J Cardiol Aug 6 2010;143(1):e14–6. [4] Attar MN, Sharman DC, Al-Najjar Y, Moore RK, Millner RW, Khan SX. A rare case of multiple right heart myxomas. Int J Cardiol May 31 2007;118(2):e66–7. [5] Parissis JT, Zezas S, Sfiras N, Kastellanos S. An atypical left atrial myxoma causing intracavitary pressure gradient and typical diastolic transmitral flow of severe mitral stenosis. Int J Cardiol Jun 22 2005;102(1):165–7. [6] Yazici M, Norgaz T, Akdemir R, Albayrak S. Asymptomatic giant left atrial myxoma supplied from right coronary artery in a 65-year-old woman. Int J Cardiol Jun 8 2005;101(3):495–6. [7] Dattilo G, Lamari A, Messina F, et al. The chance finding at multislice computed tomography coronary angiography of an ectopic origin of the left circumflex coronary artery from the right sinus of Valsalva. Int J Cardiol Jun 2 2011;149(2): e43–6. [8] Dattilo G, Carerj S, Lamari A, et al. The chance finding at multislice computed tomography coronary angiography of myocardial bridging. Int J Cardiol Jan 26 2012;154(2):e21–3. [9] Gogas BD, Rallidis LS, Iliodromitis EK, Kremastinos DT. Right atrial myxoma presenting as syncope due to pulmonary embolism in a previously asymptomatic patient. Int J Cardiol Apr 14 2011;148(2):e34–6. [10] Acikel M, Yekeler I, Ates A, Erkut B. A giant left atrial myxoma: an unusual cause of syncope and cerebral emboli. Int J Cardiol Apr 2004;94(2–3):325–6. [11] Dattilo G, Tulino V, Tulino D, Lamari A, Marte F, Patanè S. Interatrial defect, ventricular septal defect and patent ductus arteriosus in a 2-day-old newborn infant. Int J Cardiol May 15 2009;134(2):e82–3. [12] Patanè S, Marte F, Sturiale M, Dattilo G. ST-segment elevation and diminution of prostate-specific antigen in a patient with coronary spasm and without significant coronary stenoses. Int J Cardiol Apr 14 2011;148(2):e31–3. [13] Patanè S, Marte F, Dattilo G, Sturiale M. Acute myocardial infarction and left bundle branch block with changing axis deviation. Int J Cardiol Feb 9 2012;154(3):e47–9. [14] Braun S, Schrötter H, Reynen K, Schwencke C, Strasser RH. Myocardial infarction as complication of left atrial myxoma. Int J Cardiol May 11 2005;101(1):115–21. [15] Panos A, Kalangos A, Sztajzel J. Left atrial myxoma presenting with myocardial infarction. Case report and review of the literature. Int J Cardiol Oct 31 1997;62(1):73–5. [16] Tulino D, Imbalzano E, Casale M, et al. Treatment failure of low molecular weight heparin in diabetic patient. Int J Cardiol 2013 Sep 30;168(2):e63–4. [17] Milicevic G, Gavranovic Z, Cupic H, et al. Unremitting embolus from cardiac myxoma at circumflex artery trifurcation. Int J Cardiol Jun 6 2008;126(3): 424–6. [18] Alexiou K, Wilbring M, Matschke K. Angina pectoris as first manifestation of a huge biatrial myxoma. Acta Cardiol Oct 2009;64(5):667–8.
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E. Imbalzano et al. / International Journal of Cardiology 172 (2014) e165–e166
Fig. 1. Panel A and B: Transesophageal echocardiography shows a left atrial myxoma arising from the atrial septum. Panel C and Panel D: Coronaric angiography shows absence of coronaric lesions. [19] Kolvekar SK, Keal R, Spyt T. Unusual presentation of an atrial septal aneurysm with left atrial myxoma: a case report. Int J Cardiol Apr 18 1997;59(2):197–8. [20] Tulino V, Cacace C, Tulino D, Imbalzano E, Dattilo G. Clinical variants in Ebstein's anomaly. Int J Cardiol 2013 Oct 12;168(5):4969–70. [21] Mandraffino G, Sardo MA, Riggio S, et al. Circulating progenitor cells are increased in newly diagnosed untreated hypertensive patients with arterial stiffening but normal carotid intima-media thickness. Hypertens Res Jul 2011;34(7):876–83. [22] Mandraffino G, Sardo MA, Riggio S, et al. Smoke exposure and circulating progenitor cells: evidence for modulation of antioxidant enzymes and cell count. Clin Biochem Dec 2010;43(18):1436–42. [23] Sardo MA, Mandraffino G, Campo S, et al. Biglycan expression in hypertensive subjects with normal or increased carotid intima-media wall thickness. Clin Chim Acta Aug 2009;406(1–2):89–93. [24] Dattilo G, Lamari A, Crosca S, et al. Correlation between insulin resistance and endothelial dysfunction assessed by flow-mediated dilation. Recenti Prog Med Sep 2012;103(9):328–32. [25] Sardo MA, Mandraffino G, Riggio S, et al. Effects of the angiotensin II receptor blocker losartan on the monocyte expression of biglycan in hypertensive patients. Clin Exp Pharmacol Physiol Sep 2010;37(9):933–8.
[26] Patanè S, Marte F, Sturiale M, Dattilo G. Changing axis deviation and acute myocardial infarction. Int J Cardiol Aug 18 2011;151(1):e1–3. [27] Patanè S, Marte F, Sturiale M, Dattilo G, Luzza F. Atrial flutter, ventricular tachycardia and changing axis deviation associated with scleroderma. Int J Cardiol Dec 1 2011;153(2):e25–8. [28] Patanè S, Marte F, Dattilo G, Sturiale M. Changing axis deviation during atrial fibrillation. Int J Cardiol Jan 12 2012;154(1):e1–3. [29] Tsai SK. The role of transesophageal echocardiography in clinical use. J Chin Med Assoc 2013 Dec;76(12):661–72. [30] Dattilo G, Lamari A, Tulino V, et al. Congenital valvular heart disease with high familial penetrance. Recenti Prog Med Dec 2012;103(12):581–3. [31] Baglini R. Intracardiac echocardiography in monitoring atrial septal defect percutaneous closure: initial experience in an adult laboratory. Int J Cardiol Jan 8 2007;114(2):274–6. [32] Imbalzano E, Dattilo G, Scarpelli M, Lo Gullo A, Saitta A. Left coronary artery fistula to right ventricle complicated heart failure in a patient on hemodialysis. Intern Emerg Med 2013 Dec;8(8):765–6. [33] Han JH, Shin DH, Lee HJ, et al. Routine preprocedural transesophageal echocardiography might not be necessary for stroke prevention evaluation in AF patients on anticoagulation therapy. Int J Cardiol 2013 Oct 3;168(3):1992–6.
