CASE REPORT atrial myxoma
Atrial Myxoma Associated With Inferior Myocardial Infarction Acute myocardial infarction is a rare complication of left atrial myxoma. We report the case of a 44-year-old man who suffered an acute inferior myocardial infarction and systemic embolization to the lower extremities and brain resulting from m y x o m a t o u s embolization. This diagnosis should be considered in a young person presenting with systemic embolization and acute myocardial infarction. [Romisher SC, Cannon LA, Davakis N: Atrial m y x o m a associated with inferior myocardial infarction. Ann Emerg Med November 1991;20:1236-1238.] INTRODUCTION Atrial m y x o m a is the most c o m m o n primary t u m o r of the heart.1 Sites of embolization can either be isolated or occur in multiple sites in the body. Diagnosis is obscured by a myriad of nonspecific symptoms. There are only scattered reports of myocardial infarction as a direct result of atrial myxoma, and none has been previously reported in the emergency medicine literature. We report the case of a patient with this rare complication of atrial m y x o m a and review the existing literature.
CASE REPORT A 44-year-old man presented to the emergency department after being resuscitated successfully from cardiac arrest. Paramedics were dispatched after the patient complained of chest pain, left arm numbness, and dyspnea during intercourse. Prehospital providers noted an initial blood pressure of 78 m m Hg by palpation; pulse, 76; and nonlabored respirations, 18. On having a peripheral IV line placed, the patient developed bradycardia, with a heart rate of 32. Atropine 0.5 mg as well as a saline fluid bolus were given intravenously, and military anti-shock trousers were applied but not inflated. Shortly afterward, the patient became asystolic and was intubated and transported to the ED with standard advanced cardiac life support protocol. On arrival in the ED, spontaneous circulation had resumed. The patient was nasotracheally intubated and had rare spontaneous respirations. Vital signs were blood pressure in the left arm of 156/28 m m Hg and in the right arm of 160/22 m m Hg; pulse, 140; and tympanic temperature, 37.5 C. The patient was a well-developed m a n with decorticate posturing and no spontaneous eye or extremity m o t o r movement. Pupils were dilated and unreactive to light. Cardiac examination revealed a regular rate and r h y t h m w i t h o u t murmurs, gallops, clicks, or rubs. The abdominal examination was negative for pulsatile masses and distension. There was a diminished radial pulse on the right side with bounding 2 + radial pulse on the left side. Femoral pulses could not be palpated or auscultated despite the use of a Doppler stethoscope. Skin in the lower extremities was cool and mottled with livedo reticularis. The trunk and upper extremities were w a r m and dry with normal capillary refill. The patient's medical history was significant for a reported myocardial infarction eight years earlier; however, he was not on any medication. The family stated that the patient had complained of a prolonged course of fatigue, shortness of breath, dizziness, and orthopnea. Because of this, he had an appointment to see a cardiothoracic surgeon but had not been seen before admission.
96~236
Annals of Emergency Medicine
Stephen C Romisher, MD*t Westerville, and Marion, Ohio Louis A Cannon, MD:~ Saginaw, Michigan Nicholas Davakis, MD, FACC§ Columbus, Ohio From the Department of Emergency Medicine, St Ann's Hospital, Westerville, Ohio;* the Department of Emergency Medicine, Marion General Hospital, Marion, Ohio;l- Departments of Cardiology and Emergency Medicine, Michigan State University, The Heart Group, Saginaw;¢ and Department of Cardiology, Grant Medical Center, Columbus, Ohio.§ Received for publication September 5, 1990. Revision received May 31, 1991. Accepted for publication June 12, 1991. Address for reprints: Stephen C Romisher, MD, Department of Emergency Medicine, St Ann's Hospital, 500 South Cleveland Avenue, Westerville Ohio 43081.
20:11 November 1991
ATRIAL MYXOMA Romisher, Cannon & Davakis
FIGURE. Two-dimensional echocardiogram in the apical four-chamber view demonstrating a left atrial myxoma (open arrows) popping in and out of the mitra] orifice. Open arrow, myxoma; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
Twelve-lead ECG showed an acute inferior myocardial infarction with reciprocal changes in leads aVL and I. Portable chest radiograph showed a normal cardiac silhouette and pulm o n a r y edema. T w o - d i m e n s i o n a l echocardiography performed on an emergency basis showed a 2-cm left atrial myxoma in addition to inferior wall akinesis (Figure). The patient was transferred to the ICU. Despite inotropic and ventilatory support, he showed deterioration of his h e m o d y n a m i c status w i t h o u t neurologic i m p r o v e m e n t . Computed tomography of the head showed multiple small infarcts. The f a m i l y requested " c o m f o r t c a r e " measures, and he died 24 hours later. A u t o p s y disclosed a 2.0-cm left atrial m y x o m a with m y x o m a t o u s embolization to the coronary and femoral arteries.
DISCUSSION Intracardiac myxoma is the most c o m m o n b e n i g n t u m o r of t h e heart.l, 2 About 75% of m y x o m a s originate in the left atrium and 20% are located in the right atrium; they are rarely found in the ventricles. Bilateral myxomas have been reported, and myxomas may vary in size from a few millimeters to 10 cm.3, 4 Although more often benign than not, myxomas have exhibited the aggressive characteristics of malignant neoplasms with local recurrence, invasion of the chest wall, and distant metastases. 4-9 Myxomas occur most often in those from 30 to 60 years old, and there is a male-to-female p r e d o m i n a n c e of between 1:1 and 1:3. lo The clinical manifestations of left atrial myxoma may be grouped into one of three categories: obstructive, constitutional, or embolic.
Obstructive Features The obstructive features are the most common; because left atrial m y x o m a s p r e d o m i n a t e , a pseudomitral stenosis pattern is often seen. The features often include dys20:11 November 1991
pnea, fatigue, and weakness, as illustrated by our patient. More advanced cases may experience syncope and congestive heart failure. A key distinguishing feature not present in mitral stenosis is the presence of an a u s c u l t a t o r y " t u m o r p l o p . " This early diastolic sound is produced as the t u m o r strikes the ventricular wall and is characteristically intermittent.11 From the two-dimensional echocardiogram (Figure), it is easy to understand the m e c h a n i s m of this auscultatory hallmark. Right atrial m y x o m a s often produce features of tricuspid stenosis and right-sided heart failure. With obstruction of the inferior vena cava, the tumor can mimic Budd-Chiari syndrome, with hepatomegaly and ascites. Left v e n t r i c u l a r and right ventricular myxomas may produce outflow tract obstruction, with signs and s y m p t o m s of aortic and pulmonic stenoses. 4
Constitutional Features Constitutional features of cardiac myxomas are present in more than 50% of patients and include fever, myalgias, arthralgias, cachexia, muscle weakness, weight loss, Raynaud's phenomenon, rash, and clubbing, lo-12 Symptoms may be nonspecific with malaise predominating, as in our patient. Laboratory findings may include leukocytosis, thrombocytosis, t h r o m b o c y t o p e n i a , anemia, polycythemia, elevated erythrocyte sediAnnals of Emergency Medicine
mendation rate, and the presence of antimyocardial antibodies. These manifestations are nonspecific and often mimic other diseases, such as infective endocarditis, connective tissue disease, and vasculitis.
Embolic Features Embolic features can also give rise to arterial aneurysms in multiple areas or arterial occlusion in the retinal arteries, upper extremities, lower extremities, brain, liver, spleen, a n d kidneys.IS-18 Our p a t i e n t ' s p r e s e n t a t i o n was largely that of a complicated inferior wall myocardial infarction. There have been several reports of tumor emboli to the coronary arteries producing myocardial infarction.l,3, ls-~6 The two-dimensional echocardiogram established the diagnosis in our case and is the procedure of choice in the evaluation of the patient with suspected atrial myxoma. It has replaced angiography as a safe, comfortable, and noninvasive test with high sensitivity and specificity.2, 4 Transesophageal echocardiography has recently shown an even greater sensitivity than transthoracic echocardiography in diagnosing left atrial tumors. However, this test is relatively more invasive and not readily available in some communities.~, 27 Since the introduction of two-dimensional ech0cardiography, the number of diagnosed a s y m p t o m a t i c myxomas has increased. Often, a left 1237/97
ATRIAL MYXOMA Romisher, Cannon & Davakis
atrial mass may be noted that is difficult to differentiate from t h r o m b u s in the atrial appendage or attached to the left atrial wall. A trial of heparin therapy and repeat echocardiography may be helpful C o n t i n u o u s w a v e and c o l o r - f l o w D o p p l e r u l t r a s o u n d can q u a n t i f y pseudovalvular stenosis or regurgitation caused by the tumor. Catheterization and invasive angiography are indicated w h e n echocardiography is equivocal or another cardiac disease such as coronary obstruction is suspected, a O n c e diagnosed, p r o m p t surgical resection is necessary to avert future complications as seen in our patient. The extent of surgical resection necessary to prevent recurrence is a matter of o n g o i n g controversy. Recurrence of m y x o m a after removal has been reported in as m a n y as 14% of patients; patients s h o u l d have follow-up echocardiograms yearly after m y x o m a r e s e c t i o n b e c a u s e of the risk of local recurrence.a, 11 SUMMARY The case of a 44-year-old patient w h o presented to the ED after successful r e s u s c i t a t i o n from a s y s t o l e was discussed. He was found to have an acute inferior myocardial infarction and peripheral embolization resuiting from an atrial m y x o m a . This rare case should alert the emergency
98/1238
physician to atrial m y x o m a as a potential e m b o l i c source. The authors thank Mrs Becky Blackburn for research assistance. REFERENCES L Lehrman KL, Prozan GB, Ullyot D: Atrial myxoma presenting as acute myocardial infarction. A m Heart J 1985;110:1293-1295. Z. Polanco GA, Alam M, Haggar AM, et ah Clinical and laboratory features of small left atrial myxomas. Henry Ford Hosp Med J 1989;37:63-65. 3. Balk AHM, Wagenaar SS, Bruschke AVG: Bilateral myxomas and peripheral myxomas in a patient with recent myocardial infarction. A m J Cardiol 1979;44: 767 770. 4. Tabbalat RA, Haft JI: Left atrial myxoma. NJ Med 1989;86:785-788. 5. Attum AA, Johnson GS, Masri Z, et ah Malignant clinical behavior of cardiac myxomas and "myxoid imitators." Ann Thorac Surg 1987;44:217-222. 6. Ng HK, Poon WS: Cardiac myxoma metastasizing to the brain. J Neurosurg 1990;72:295-298. 7. Hannah H III, Eisemann G, Hiszcznskyj R, et al: Invasive atrial myxoma: Documentation of malignant potential of cardiac myxomas. A m Heart J 1982;104: 881-883. 8. Read RJ, Utz MP, Terezakis N: Malignant potentiality of left atrial myxomas. J Thorac Cardiovasc Surg 1974~68:857-868. 9. Angelini GD, Fraser AG, Butchart EG, et al: A report and review of recurrent left atrial myxoma: Not always such "a benign tumor." Eur T Cardiothorac Surg 1988; 2:465-468. 10. Silverman J, Olwin JS, Graettinger J8: Cardiac myxomas with systemic embolization: Review of the literature and report of a case. Cimufation 1962;26:99-102. 11. Z i t n i k RS, G i u l i a n i ER: Clinical recognition of atrial myxoma. Am Heart ] 1970;80:689 700. 12. Thomas MH: Myxoma masquerading as polyar teritis nodosa. J Rheumatol 1981;8:133-137.
Annals of Emergency Medicine
13. St John-Sutton MG, Mercier LA, Giuliana ER, et ah Atrial myxomas: A review of clinical experience in 40 patients. Mayo Clin Proc 1980;55:371-376. 14. Yasuma F, Tsuzuki M, Yasuma T: Retinal embo lism from left atrial myxoma. Jpn Heart J 1989;30: 527-532. 15. Kaar G, Broe PJ, Bouchier-Hayes DJ: Upper limb emboli. J Cardiovasc Surg 1989;30:165-168. 16. Weerasena NA, Groome D, Pollock JG, et al: Atrial myxoma as the cause of acute lower limb ischaemia in a teenager. Scot Med J 1989;34:440-441. 17. Michael AS, Mikhael MA, Christ M: Myxoma of the heart presenting with recurrent episodes of hemorrhagic cerebral infarction: MR findings. J Comput Assist Tomogr 1989;13:123-125. 18. Rath S, Yadel H, Battlet A, et ah Coronary arterial e m b o l u s from left atrial myxoma. A m J Cardiol 1984;54:1392-1393. 19. Wenger NK, Bauer S: Coronary embolism: Review of the literature and presentation of fifteen cases. A m J Med 1958;25:549-557. 20. Niccolini A, Arcuri G, Bartoccioni S: Quadro di infarcto miocardico acuto in una paziente con mixima atriale sinistro. G Itaf CardioI 1989;19:355 359. 21. Usui A, Murase M, Tanaka M, et al: A case of left atrial myxoma with acute myocardial infarction. J Jpn Assoc Thorac Surg I987;35:242-245. 22. Hoad NA, Foulds JS: Fortuitous discovery of a left atrial myxoma following acute myocardial infarction. J R Army Med Corps 1987;133:13-15. 23. Abad C, Serra J, Condom E, et al: Infamto de rai ocardo en una mujer joven con un mixoma auricular izquierdo. Rev Esp CardioI 1989;42:485-488. 24. Doi Y, Ogawa K, Nakagaki O, et al: A case of left atrial myxoma complicated with acute myocardial infarction. Respir Circ 1988;36:211-215. 25. YahaIom M: Left atrial myxoma presenting as acute myocardial infarction. HarefuJah 1979;96: 575-576. 26. Tanabe J, Williams RL, Diethrich EB: Left atrial myxoma: Association with acute coronary embolization in an ll-year-old boy. Pediatrics 1979;63:778-781. 27. Khandheria BK, Seward JB, Oh JK, et al: Is transesophageal echocardiography indicated in the assessment of iutracardiac masses? Circulation 1988;78Isuppl II):II-29.
20:11 November 1991
Atrial Myxoma Associated With Inferior Myocardial Infarction Acute myocardial infarction is a rare complication of left atrial myxoma. We report the case of a 44-year-old man who suffered an acute inferior myocardial infarction and systemic embolization to the lower extremities and brain resulting from m y x o m a t o u s embolization. This diagnosis should be considered in a young person presenting with systemic embolization and acute myocardial infarction. [Romisher SC, Cannon LA, Davakis N: Atrial m y x o m a associated with inferior myocardial infarction. Ann Emerg Med November 1991;20:1236-1238.] INTRODUCTION Atrial m y x o m a is the most c o m m o n primary t u m o r of the heart.1 Sites of embolization can either be isolated or occur in multiple sites in the body. Diagnosis is obscured by a myriad of nonspecific symptoms. There are only scattered reports of myocardial infarction as a direct result of atrial myxoma, and none has been previously reported in the emergency medicine literature. We report the case of a patient with this rare complication of atrial m y x o m a and review the existing literature.
CASE REPORT A 44-year-old man presented to the emergency department after being resuscitated successfully from cardiac arrest. Paramedics were dispatched after the patient complained of chest pain, left arm numbness, and dyspnea during intercourse. Prehospital providers noted an initial blood pressure of 78 m m Hg by palpation; pulse, 76; and nonlabored respirations, 18. On having a peripheral IV line placed, the patient developed bradycardia, with a heart rate of 32. Atropine 0.5 mg as well as a saline fluid bolus were given intravenously, and military anti-shock trousers were applied but not inflated. Shortly afterward, the patient became asystolic and was intubated and transported to the ED with standard advanced cardiac life support protocol. On arrival in the ED, spontaneous circulation had resumed. The patient was nasotracheally intubated and had rare spontaneous respirations. Vital signs were blood pressure in the left arm of 156/28 m m Hg and in the right arm of 160/22 m m Hg; pulse, 140; and tympanic temperature, 37.5 C. The patient was a well-developed m a n with decorticate posturing and no spontaneous eye or extremity m o t o r movement. Pupils were dilated and unreactive to light. Cardiac examination revealed a regular rate and r h y t h m w i t h o u t murmurs, gallops, clicks, or rubs. The abdominal examination was negative for pulsatile masses and distension. There was a diminished radial pulse on the right side with bounding 2 + radial pulse on the left side. Femoral pulses could not be palpated or auscultated despite the use of a Doppler stethoscope. Skin in the lower extremities was cool and mottled with livedo reticularis. The trunk and upper extremities were w a r m and dry with normal capillary refill. The patient's medical history was significant for a reported myocardial infarction eight years earlier; however, he was not on any medication. The family stated that the patient had complained of a prolonged course of fatigue, shortness of breath, dizziness, and orthopnea. Because of this, he had an appointment to see a cardiothoracic surgeon but had not been seen before admission.
96~236
Annals of Emergency Medicine
Stephen C Romisher, MD*t Westerville, and Marion, Ohio Louis A Cannon, MD:~ Saginaw, Michigan Nicholas Davakis, MD, FACC§ Columbus, Ohio From the Department of Emergency Medicine, St Ann's Hospital, Westerville, Ohio;* the Department of Emergency Medicine, Marion General Hospital, Marion, Ohio;l- Departments of Cardiology and Emergency Medicine, Michigan State University, The Heart Group, Saginaw;¢ and Department of Cardiology, Grant Medical Center, Columbus, Ohio.§ Received for publication September 5, 1990. Revision received May 31, 1991. Accepted for publication June 12, 1991. Address for reprints: Stephen C Romisher, MD, Department of Emergency Medicine, St Ann's Hospital, 500 South Cleveland Avenue, Westerville Ohio 43081.
20:11 November 1991
ATRIAL MYXOMA Romisher, Cannon & Davakis
FIGURE. Two-dimensional echocardiogram in the apical four-chamber view demonstrating a left atrial myxoma (open arrows) popping in and out of the mitra] orifice. Open arrow, myxoma; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
Twelve-lead ECG showed an acute inferior myocardial infarction with reciprocal changes in leads aVL and I. Portable chest radiograph showed a normal cardiac silhouette and pulm o n a r y edema. T w o - d i m e n s i o n a l echocardiography performed on an emergency basis showed a 2-cm left atrial myxoma in addition to inferior wall akinesis (Figure). The patient was transferred to the ICU. Despite inotropic and ventilatory support, he showed deterioration of his h e m o d y n a m i c status w i t h o u t neurologic i m p r o v e m e n t . Computed tomography of the head showed multiple small infarcts. The f a m i l y requested " c o m f o r t c a r e " measures, and he died 24 hours later. A u t o p s y disclosed a 2.0-cm left atrial m y x o m a with m y x o m a t o u s embolization to the coronary and femoral arteries.
DISCUSSION Intracardiac myxoma is the most c o m m o n b e n i g n t u m o r of t h e heart.l, 2 About 75% of m y x o m a s originate in the left atrium and 20% are located in the right atrium; they are rarely found in the ventricles. Bilateral myxomas have been reported, and myxomas may vary in size from a few millimeters to 10 cm.3, 4 Although more often benign than not, myxomas have exhibited the aggressive characteristics of malignant neoplasms with local recurrence, invasion of the chest wall, and distant metastases. 4-9 Myxomas occur most often in those from 30 to 60 years old, and there is a male-to-female p r e d o m i n a n c e of between 1:1 and 1:3. lo The clinical manifestations of left atrial myxoma may be grouped into one of three categories: obstructive, constitutional, or embolic.
Obstructive Features The obstructive features are the most common; because left atrial m y x o m a s p r e d o m i n a t e , a pseudomitral stenosis pattern is often seen. The features often include dys20:11 November 1991
pnea, fatigue, and weakness, as illustrated by our patient. More advanced cases may experience syncope and congestive heart failure. A key distinguishing feature not present in mitral stenosis is the presence of an a u s c u l t a t o r y " t u m o r p l o p . " This early diastolic sound is produced as the t u m o r strikes the ventricular wall and is characteristically intermittent.11 From the two-dimensional echocardiogram (Figure), it is easy to understand the m e c h a n i s m of this auscultatory hallmark. Right atrial m y x o m a s often produce features of tricuspid stenosis and right-sided heart failure. With obstruction of the inferior vena cava, the tumor can mimic Budd-Chiari syndrome, with hepatomegaly and ascites. Left v e n t r i c u l a r and right ventricular myxomas may produce outflow tract obstruction, with signs and s y m p t o m s of aortic and pulmonic stenoses. 4
Constitutional Features Constitutional features of cardiac myxomas are present in more than 50% of patients and include fever, myalgias, arthralgias, cachexia, muscle weakness, weight loss, Raynaud's phenomenon, rash, and clubbing, lo-12 Symptoms may be nonspecific with malaise predominating, as in our patient. Laboratory findings may include leukocytosis, thrombocytosis, t h r o m b o c y t o p e n i a , anemia, polycythemia, elevated erythrocyte sediAnnals of Emergency Medicine
mendation rate, and the presence of antimyocardial antibodies. These manifestations are nonspecific and often mimic other diseases, such as infective endocarditis, connective tissue disease, and vasculitis.
Embolic Features Embolic features can also give rise to arterial aneurysms in multiple areas or arterial occlusion in the retinal arteries, upper extremities, lower extremities, brain, liver, spleen, a n d kidneys.IS-18 Our p a t i e n t ' s p r e s e n t a t i o n was largely that of a complicated inferior wall myocardial infarction. There have been several reports of tumor emboli to the coronary arteries producing myocardial infarction.l,3, ls-~6 The two-dimensional echocardiogram established the diagnosis in our case and is the procedure of choice in the evaluation of the patient with suspected atrial myxoma. It has replaced angiography as a safe, comfortable, and noninvasive test with high sensitivity and specificity.2, 4 Transesophageal echocardiography has recently shown an even greater sensitivity than transthoracic echocardiography in diagnosing left atrial tumors. However, this test is relatively more invasive and not readily available in some communities.~, 27 Since the introduction of two-dimensional ech0cardiography, the number of diagnosed a s y m p t o m a t i c myxomas has increased. Often, a left 1237/97
ATRIAL MYXOMA Romisher, Cannon & Davakis
atrial mass may be noted that is difficult to differentiate from t h r o m b u s in the atrial appendage or attached to the left atrial wall. A trial of heparin therapy and repeat echocardiography may be helpful C o n t i n u o u s w a v e and c o l o r - f l o w D o p p l e r u l t r a s o u n d can q u a n t i f y pseudovalvular stenosis or regurgitation caused by the tumor. Catheterization and invasive angiography are indicated w h e n echocardiography is equivocal or another cardiac disease such as coronary obstruction is suspected, a O n c e diagnosed, p r o m p t surgical resection is necessary to avert future complications as seen in our patient. The extent of surgical resection necessary to prevent recurrence is a matter of o n g o i n g controversy. Recurrence of m y x o m a after removal has been reported in as m a n y as 14% of patients; patients s h o u l d have follow-up echocardiograms yearly after m y x o m a r e s e c t i o n b e c a u s e of the risk of local recurrence.a, 11 SUMMARY The case of a 44-year-old patient w h o presented to the ED after successful r e s u s c i t a t i o n from a s y s t o l e was discussed. He was found to have an acute inferior myocardial infarction and peripheral embolization resuiting from an atrial m y x o m a . This rare case should alert the emergency
98/1238
physician to atrial m y x o m a as a potential e m b o l i c source. The authors thank Mrs Becky Blackburn for research assistance. REFERENCES L Lehrman KL, Prozan GB, Ullyot D: Atrial myxoma presenting as acute myocardial infarction. A m Heart J 1985;110:1293-1295. Z. Polanco GA, Alam M, Haggar AM, et ah Clinical and laboratory features of small left atrial myxomas. Henry Ford Hosp Med J 1989;37:63-65. 3. Balk AHM, Wagenaar SS, Bruschke AVG: Bilateral myxomas and peripheral myxomas in a patient with recent myocardial infarction. A m J Cardiol 1979;44: 767 770. 4. Tabbalat RA, Haft JI: Left atrial myxoma. NJ Med 1989;86:785-788. 5. Attum AA, Johnson GS, Masri Z, et ah Malignant clinical behavior of cardiac myxomas and "myxoid imitators." Ann Thorac Surg 1987;44:217-222. 6. Ng HK, Poon WS: Cardiac myxoma metastasizing to the brain. J Neurosurg 1990;72:295-298. 7. Hannah H III, Eisemann G, Hiszcznskyj R, et al: Invasive atrial myxoma: Documentation of malignant potential of cardiac myxomas. A m Heart J 1982;104: 881-883. 8. Read RJ, Utz MP, Terezakis N: Malignant potentiality of left atrial myxomas. J Thorac Cardiovasc Surg 1974~68:857-868. 9. Angelini GD, Fraser AG, Butchart EG, et al: A report and review of recurrent left atrial myxoma: Not always such "a benign tumor." Eur T Cardiothorac Surg 1988; 2:465-468. 10. Silverman J, Olwin JS, Graettinger J8: Cardiac myxomas with systemic embolization: Review of the literature and report of a case. Cimufation 1962;26:99-102. 11. Z i t n i k RS, G i u l i a n i ER: Clinical recognition of atrial myxoma. Am Heart ] 1970;80:689 700. 12. Thomas MH: Myxoma masquerading as polyar teritis nodosa. J Rheumatol 1981;8:133-137.
Annals of Emergency Medicine
13. St John-Sutton MG, Mercier LA, Giuliana ER, et ah Atrial myxomas: A review of clinical experience in 40 patients. Mayo Clin Proc 1980;55:371-376. 14. Yasuma F, Tsuzuki M, Yasuma T: Retinal embo lism from left atrial myxoma. Jpn Heart J 1989;30: 527-532. 15. Kaar G, Broe PJ, Bouchier-Hayes DJ: Upper limb emboli. J Cardiovasc Surg 1989;30:165-168. 16. Weerasena NA, Groome D, Pollock JG, et al: Atrial myxoma as the cause of acute lower limb ischaemia in a teenager. Scot Med J 1989;34:440-441. 17. Michael AS, Mikhael MA, Christ M: Myxoma of the heart presenting with recurrent episodes of hemorrhagic cerebral infarction: MR findings. J Comput Assist Tomogr 1989;13:123-125. 18. Rath S, Yadel H, Battlet A, et ah Coronary arterial e m b o l u s from left atrial myxoma. A m J Cardiol 1984;54:1392-1393. 19. Wenger NK, Bauer S: Coronary embolism: Review of the literature and presentation of fifteen cases. A m J Med 1958;25:549-557. 20. Niccolini A, Arcuri G, Bartoccioni S: Quadro di infarcto miocardico acuto in una paziente con mixima atriale sinistro. G Itaf CardioI 1989;19:355 359. 21. Usui A, Murase M, Tanaka M, et al: A case of left atrial myxoma with acute myocardial infarction. J Jpn Assoc Thorac Surg I987;35:242-245. 22. Hoad NA, Foulds JS: Fortuitous discovery of a left atrial myxoma following acute myocardial infarction. J R Army Med Corps 1987;133:13-15. 23. Abad C, Serra J, Condom E, et al: Infamto de rai ocardo en una mujer joven con un mixoma auricular izquierdo. Rev Esp CardioI 1989;42:485-488. 24. Doi Y, Ogawa K, Nakagaki O, et al: A case of left atrial myxoma complicated with acute myocardial infarction. Respir Circ 1988;36:211-215. 25. YahaIom M: Left atrial myxoma presenting as acute myocardial infarction. HarefuJah 1979;96: 575-576. 26. Tanabe J, Williams RL, Diethrich EB: Left atrial myxoma: Association with acute coronary embolization in an ll-year-old boy. Pediatrics 1979;63:778-781. 27. Khandheria BK, Seward JB, Oh JK, et al: Is transesophageal echocardiography indicated in the assessment of iutracardiac masses? Circulation 1988;78Isuppl II):II-29.
20:11 November 1991
