Case Presentation: An 88-year-old woman with history of hypertension and hyperlipidemia presented to the ED after a fall. She denied trauma or loss of consciousness at the time of the event. Prior to the fall, she denied palpitations, chest pain, dizziness, or other prodromal symptoms. She denied prior events. She attributed her fall to swelling of her legs, which had been worsening over the past 3 weeks. Moreover, reported worsening dyspnea on exertion during this timeframe. Workup was remarkable for elevated HS troponin of 1668, BNP of 2540, and EKG which did not reveal acute ischemic changes. A chest X-ray revealed bibasilar atelectasis and small bilateral pleural effusions. An ultrasound was negative for deep venous thrombosis. She was admitted to the hospital medicine service for volume overload, with concern for new diagnosis of heart failure. She was treated with IV furosemide which improved her bilateral lower extremity edema and her dyspnea on exertion. She was clinically improving. However, an echocardiogram revealed LVEF 55-60% and a large mass measuring 6 cm x 3 cm in the left atrium. Echocardiographic features were suggestive of a cardiac myxoma. Cardiothoracic surgery was consulted for resection and estimated the surgical mortality risk to be approximately 30% in the context of patient’s age and comorbidities. After a goals of care discussion, the patient elected to not pursue surgery and chose palliative care and symptom management. The patient was placed on anticoagulation for embolic prevention and furosemide as needed for supportive care.
Discussion: Cardiac tumors are classified as either primary or secondary, most often metastatic to cancer. In the category of primary cardiac tumors, approximately 75% are benign (1, 2), and include myxomas, papillary fibroelastomas, lipomas, rhabdomyomas, and fibromas. Cardiac myxomas are rare, with the reported prevalence of 0.03% in the general population (3). Approximately 75% of myxomas originate from the left atrium, usually from the fossa ovalis (4). Presentation of atrial myxomas can include the triad of obstruction, emboli, and constitutional symptoms. Left sided myxomas can lead to mitral valve obstruction, regurgitation, or left sided heart failure, which include symptoms of dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, pulmonary edema, and syncope (5). A feared complication includes sudden cardiac death due to obstruction. Left sided myxomas are associated with increased risk of systemic embolization due to high systolic pressure, which most commonly lead to TIAs/strokes, or seizures. Emboli can affect other sites such as the retina, kidneys, mesentery, coronaries, aorta, and lower limbs (6). Constitutional symptoms can include fatigue, fever, arthralgia, myalgia, and weight loss. Cardiac myxomas are usually treated with surgical resection, which typically has good outcomes, with post-tumor excision early mortality rate of 1.27% and late mortality rate of 4.7% per 1000 person-years (7).
Conclusions: We present a case of a common admission in hospital medicine with an unusual diagnosis. Myxomas are typically treated with surgical resection, the intraoperative mortality risk for this patient was high, given her age and co-morbidities. Goals of care discussions were conducted with the patient, her family, and cardiothoracic surgery, and she ultimately decided to pursue palliative care and was discharged home on oral anticoagulation to reduce thromboembolic risk.
