584194 research-article2015
SCVXXX10.1177/1089253215584194Seminars in Cardiothoracic and Vascular AnesthesiaEssandoh et al
Clinical Challenges
Anesthetic Management of a Patient With a Giant Right Atrial Myxoma
Seminars in Cardiothoracic and Vascular Anesthesia 2016, Vol. 20(1) 104–109 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1089253215584194 scv.sagepub.com
Michael Essandoh, MD1, Michael Andritsos, MD1, Ahmet Kilic, MD1, and Juan Crestanello, MD1
Abstract Cardiac myxomas account for 50% of all benign primary cardiac tumors. Rarely, these tumors occur in the right atrium (RA; 10% to 20%), with a stalk frequently attached to the interatrial septum. Right atrial myxomas can lead to RA enlargement, arrhythmias, functional tricuspid stenosis, right heart failure, and catastophic pulmonary embolization resulting in sudden cardiac death. Anesthetic management of patients with RA myxomas can be complicated by the mass effect of the myxoma, preload limitations, and the potential for cardiovascular collapse. Multimodal cardiac imaging inclusive of echocardiography, computed tomography, and magnetic resonance imaging helps with the diagnosis, preoperative optimization, and formulation of anesthetic and surgical plans. We present a case report highlighting the importance of multimodal imaging, adequate preoperative patient optimization, and the anesthetic considerations in the successful management of a patient with a giant 8.3 × 4.7 cm RA myxoma. Keywords right atrium, general anesthesia, functional tricuspid stenosis, transesophageal echocardiography, myxoma
Introduction Cardiac myxomas are intracardiac lesions accounting for 50% of all benign primary cardiac tumors.1,2 The majority of cardiac myxomas are located in the left atrium (75%), and rarely in the right atrium (RA; 10% to 20%), with a stalk frequently attached to the interatrial septum.1,2 Right atrial myxomas can lead to RA enlargement, arrhythmias, functional tricuspid stenosis, and right heart failure resulting from intracardiac obstruction.3 Fragmentation of these tumors can result in catastophic pulmonary embolus, or systemic embolization in the setting of a patent foramen ovale or atrial septal defect.1-5 Preoperative multimodal cardiac imaging inclusive of echocardiography, computed tomography, and magnetic resonance imaging (MRI) is instrumental in formulating a diagnosis, creating an anesthetic plan, and developing a surgical strategy for resection.6 We present a case report highlighting the anesthetic considerations in the successful management of a patient with functional tricuspid stenosis, and right heart failure due to a large RA myxoma.
and palpitations was referred for cardiovascular evaluation at an outside facility. The patient’s past medical history was significant for morbid obesity (body mass index of 54 kg/m2), hypertension, hyperlipidemia, obstructive sleep apnea, and diabetes mellitus. Transthoracic echocardiogram revealed the following: normal left ventricular (LV) systolic function with an ejection fraction of 50%, severe RA enlargement (6.4 × 7.2 cm), a 6 × 5 cm RA mass that occupied greater than 50% of the right ventricular (RV) cavity during diastole, and absence of a patent foramen ovale. He was subsequently started on a heparin infusion and a cardiac catheterization was performed. This demonstrated the absence of coronary artery disease. Secondary to the severity of his symptoms and his imaging results, the patient was transferred to our institution for further management. On admission, cardiac MRI was obtained to further characterize the RA mass. The MRI showed a lobulated avascular RA myxoma attached to the inferior vena cava (IVC)–RA junction, which prolapsed through the tricuspid valve (TV) into the RV 1
The Ohio State University, Columbus, OH, USA
Case Report A 50-year-old man with a complaint of dyspnea at rest, fever, orthopnea, syncope, severe lower extremity edema,
Corresponding Author: Michael Essandoh, MD The Ohio State University Wexner Medical Center, 410 West 10th Avenue N411, Columbus, OH 43210, USA. Email:
[email protected]
Essandoh et al
Figure 1. Magnetic resonance image showing the right atrial myxoma prolapsing through the tricuspid valve during diastole into the right ventricle. RA, right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle; S, interventricular septum; M, right atrial myxoma.
Figure 2. Magnetic resonance image showing the right atrial myxoma in the right ventricle in addition to the presence of interventricular septal shift to the left secondary to elevated right ventricular diastolic pressures. LV, left ventricle; RV, right ventricle; M, right atrial myxoma.
during diastole (Figure 1). In addition, the RV was dilated and partially obstructed by the RA mass (Figure 2). The
105 interventricular septum was deviated to the left; however, the LV had normal systolic function with an ejection fraction of 55%. Laboratory results were significant for mildly elevated levels of alkaline phosphatase of 275 U/L (normal
