Q J Med 2014; 107:853–854 doi:10.1093/qjmed/hcu047 Advance Access Publication 5 March 2014

Clinical picture Left atrial myxoma complicated with acute embolism of left ulnar artery Atrial myxoma is the most common benign tumour of the heart, accounting for approximately 50% of all cardiac tumours.1 Patient with atrial myxoma usually present with intracardiac obstruction, arrhythmia, central nervous system embolization or peripheral embolization. Embolization from tumour fragmentation or complete tumour detachment comprises up to 30% of arterial embolism cases.1 The most frequent embolization occurs in the central nervous system, causing cerebrovascular accidents, followed by coronary arteries, kidneys, intestines and peripheral arteries.2 Peripheral embolization is rare with a low incidence of 0.23% as reported in the literature.3 The key to diagnosis of atrial myxomas relies on prompt recognition of arterial embolism-related symptoms and signs plus high index of suspicion of cardiac tumour in patients who present with acute arterial ischaemia.4 TOE is the gold standard of diagnostic method,5 and operative resection remains the treatment of choice for atrial myxomas.

Figure 1. (A) Compared with right hand, left forearm and hand showed paleness along the ulnar side (arrows); (B) TOE showed a mobile lobulated mass of 2.44  2.58 cm in the left atrium attaching to the inter-atrial septum (arrow heads).

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A 74-year-old woman presented to the emergency department with acute onset of pallor, pain and numbness over her left hand. She had a history of right hemicolectomy for colon cancer. There was no history of trauma or recent fever. On examination, paleness, coldness and weak pulses were noted along the ulnar side of her left forearm and hand (Figure 1A). Radial artery pulses at the wrist were normal. The neurologic examinations were normal over the distribution area of radial and median nerves. Computerized tomography angiography and 3D reconstruction showed an embolus in her left ulnar artery at the elbow level. Transoesophageal echocardiography (TOE) was performed to assess for cardiac thrombus or tumour. The TOE showed a mobile lobulated mass of 2.44  2.58 cm in the left atrium attaching to the inter-atrial septum (Figure 1B). The embolization of left ulnar artery due to atrial myxoma was confirmed by histopathologic findings of specimens removed during the embolectomy procedure and open heart surgery.

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Clinical picture

Conflict of interest: None declared. Photographs and text from: Y.-C. Chen, Department of Emergency Medicine, Taipei Veterans General Hospital and Institute of Environmental and Occupational Health Sciences, National YangMing University, Taipei, Taiwan; C. Wan, Servic¸o Urgeˆncia, Centro Hospitalar Conde de Sa˜o Janua´rio (CHCSJ) and Universidade de Macau, Macau; M.-H. Chen, Vigor Medical Institute, Taoyuan, Taiwan; C.-K. How, Department of Emergency Medicine, Taipei Veterans General Hospital and Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan. email: [email protected]

References

imaging approach and surgical outcome in a large contemporary series. Interact Cardiovasc Thorac Surg 2007; 6:479–83. 2. Liesting C, Ramjankhan FZ, van Herwerden LA, Kofflard MJ. Systemic embolisation as presentation and recurrence of cardiac myxoma two years after surgery. Neth Heart J 2010; 18:499–502. 3. Chiba K, Abe H, Kitanaka Y, Makuuchi H. Left atrial myxoma complicated with an acute upper extremity embolism. Ann Thorac Cardiovasc Surg 2012; 18:391–4. 4. Coley C, Lee KR, Steiner M, Thompson CS. Complete embolization of a left atrial myxoma resulting in acute lower extremity ischemia. Tex Heart Inst J 2005; 32:238–40. 5. Engberding R, Daniel WG, Erbel R, Kasper W, Lestuzzi C, Curtius JM, et al. Diagnosis of heart tumours by transoesophageal echocardiography: a multicentre study in 154 patients. European Cooperative Study Group. Eur Heart J 1993; 14:1223–8.

1. Rahmanian PB, Castillo JG, Sanz J, Adams DH, Filsoufi F. Cardiac myxoma: preoperative diagnosis using a multimodal

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Left atrial myxoma complicated with acute embolism of left ulnar artery.

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