Myxoma
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MYXOMA. PH SONNEKUS. LECTURE OUTCOMES. Case discussions 1-3 Definition Histology Macroscopic appearance Clinical presentation Diagnosis Management Prognosis. CASE 1. 61 yr male from Petrusburg Referred to internal medicine Pelonomi from orthopaedic ward

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Myxoma

MYXOMA

PH SONNEKUS


Lecture outcomes

LECTURE OUTCOMES

  • Case discussions 1-3

  • Definition

  • Histology

  • Macroscopic appearance

  • Clinical presentation

  • Diagnosis

  • Management

  • Prognosis


Case 1

CASE 1

  • 61 yr male from Petrusburg

  • Referred to internal medicine Pelonomi from orthopaedic ward

  • Conservative Rx for a left pubic rami fracture

  • Workup for surgery: heartsonar revealed a mobile mass in the right atrium


Case 11

CASE 1

  • Medical Hx:

    • Hypertension

  • Current treatment

    • Ridaq and Renitec

  • Allergies:

    • none

  • Previous surgery:

    • none

  • Hospital admissions:

    • none


Case 12

CASE 1

  • Systemic history:

    • CVS:

      • No ortopnoea or PND

      • Dyspnoea NYHA gr 2

      • No palipations

      • No oedema

      • Atypical chestpain-associated with heartburn

  • CNS:

    • vague history of syncope

  • RESP:

    • no complains

  • ABD:

    • no comlpains


Case 13

CASE 1

  • On Examination:

    • Vitals:

      • BP 170/100 mmHg

      • HR: 82 bpm, regular and strong

      • Sats: 98%

      • No fever

    • General:

      • no anaemia, oedema or cyanosis


Case 14

CASE 1

  • On examination:

    • CVS:

      • No Sx of fluid overload

      • Pulses felt

      • Apex normal 5th ICS MCL

      • S1 and S2 normal

      • No murmers

    • All other systems normal


Case 15

CASE 1

  • Spesial investigations:

    • Heartsonar:

      • mobile mass in the right atria

      • (?Thrombus/vegitation/myxoma)

    • ECG:

      • Left ventrucular hypertophy


Case 2

CASE 2

  • 62 yr Female from Winburg

  • Urology, December 2009 with c/o hematuria

  • Pre-op workup for TURBT

  • Presenting complaint: syncope and decreased effort tolerance


Case 21

CASE 2

  • Previous Medical History:

    • Hypertension, COPD, Ulserativecollitis, Papillary bladder tumour

  • Social:

    • 90 pack year smoking history

  • Current treatment:

    • Adalat XL, Enalapril, Inflammide and Asthavent inhalers

  • Allergy:

    • Penicillin, Sulphas, Aspirin, Elastoplast

  • Previous Surgery:

    • Appendisectomy, TURBT, Cholycystectomy, Hiatus hernia repair


Case 22

CASE 2

  • On Examination

    • Vitals

      • BP 125/62mmHg

      • HR: 78 bpm, regular and strong

      • Temp: 36.2

    • No Sx of anaemia, cyanosis or oedema


Case 23

CASE 2

  • On examination:

    • CVS:

      • All peripheral pulses palpalble

      • No sx of fluid overload

      • Apex not diplaced

      • S1 and S2 normal

      • No murmers


Case 24

CASE 2

  • Special investigations

    • MRI:

      • LA mass 2 x 1.7 cm

    • CXR

    • TEE


Pre op cxr

Pre op CXR


Pre op mri

Pre op MRI


Special investigations

SPECIAL INVESTIGATIONS

  • Heartsonar:

    • Mass in left atrium

  • Angiogram:

    • Significant stenosis of 80% on circumflex artery

    • Intermediate lesion on LAD


Cardiothoracic surgery excision myxoma

Cardiothoracic Surgery:Excision myxoma


Myxoma1

Myxoma


Myxoma2

Myxoma


Myxoma3

Myxoma


Case 3

CASE 3

  • 56 yr female from Phuthaditjana

  • Presenting Complaint: Dyspnoea NYHA gr 2 and atypical chest pain


Case 31

CASE 3

  • Previous Medical History:

    • Hypertension

  • Current treatment:

    • Pharmapress, Ridaq, Adalat XL, Slow K

  • Previous surgery:

    • none

  • Allergies:

    • None

  • Other:

    • Jehova’s witness


Case 32

CASE 3

  • On examination

    • Vitals:

      • BP 117/92mmHg

      • HR 90 bpm, irregular-irregular

      • Sats: 97%

    • General:

      • no oedema, anaemia, cyanosis


Case 33

CASE 3

  • On examination

    • CVS :

      • all peripheral pulses palpable

      • JVP raised

      • Apex 5th ICS AAL

      • S1 , S2 no S3

      • Tricuspid incompetence 2/6

  • RESP

    • no abnormalities

  • GIT

    • no abnormalities


Special investigations1

SPECIAL INVESTIGATIONS

  • Heartsonar:

    • mass in right atrium Pulmonary hypertention

  • ECG:

    • Slow atrial fibrilation


Cardiothoracic surgery excision myxoma1

Cardiothoracic Surgery:Excision myxoma


Discussion

DISCUSSION


Introduction

INTRODUCTION

  • Adults

  • >75% of primary cardiac tumors are benign

  • Majority of benign lesions are myxomas


Carney complex

CARNEY COMPLEX

  • Inherited, outosomal dominant disorder

  • Consists of the following:

    • Cardiac and mucocutaneous myxomas

    • Lentiginosis

    • Endocrine dysfunction (Bilateral adrenal micronodular hyperplasia- may lead to Cushing’s syndrome)


Definition

DEFINITION

  • Myxo = new Latin from Greek word Muxa for mucos

  • A tumor of primitive connective tissue, filled with mucos


Histology

HISTOLOGY

  • Scattered cells with a mucopolysaccharide stroma.

  • Cells originate from a multipotent mesenchyme capable of neural and endothelial differentiation

  • Produce vascular endothelial growth factor

  • Angiogenisis and early stages of tumor growth


Macroscopic appearance

MACROSCOPIC APPEARANCE

  • Pendunculated

  • Gelatinous in consistancy

  • Surface: smooth, villous or friable

  • Vary wildly in size, ranging from 1-15cm in diameter

  • Weight anything from 15-189g


Clinical manifestations

CLINICAL MANIFESTATIONS

  • Cardiovascular manifestations depend upon anatomic location.

  • +/- 80% of myxomas originate in left atrium, remainder are found in the right atrium.


Left atrial myxoma

LEFT ATRIAL MYXOMA


Left atrium

LEFT ATRIUM

  • Grow into atrial lumen and cause symptoms of obstructing bloodflow or creating mitral regurgitation.

  • May simulate mitral valve disease

  • Produce heartfailure

  • Pulmonary hypertention


Left atrium1

LEFT ATRIUM


Left atrium2

LEFT ATRIUM

  • Symptoms and signs

    • Dyspnoea

    • Ortopnoea

    • PND

    • Pulmonary oedema

    • Cough

    • Hemoptises

    • Fatigue


Left atrium3

LEFT ATRIUM

  • Symptoms may worsen with change in position

    • Force of gravity pulls myxoma into the opening of mitral valve

  • Thrombo-embolic phenomena

    • Release tumour fragments or thrombi into systemic circulation.

    • Manifests as neurological or vascular symptoms


Right atrial myxoma

RIGHT ATRIAL MYXOMA


Right atrium

RIGHT ATRIUM

  • Pathology and haemodynamic implications:

    • Grow into atrial lumen

    • obstruct bloodflow

    • hemodynamic changes similar to tricuspid stenoses.

  • Thrombo-emobolic phenomena

    • Tumour fragments released into pulmonary circulation

    • Presents similar to pulmonary emboli.


Right atrium1

RIGHT ATRIUM

  • Symptoms and signs

    • Fatigue

    • Peripheral oedema

    • Hepatomegaly

    • Ascitis

    • Prominent a waves

    • +/- diastolic murmer


Diagnosis

DIAGNOSIS

  • Echocardiography

    • TTE

    • TEE

      • Enables to evaluate the left atrial wall

      • Nearly 100% sensitivity

  • CT

    • Demonstrates a well defined spherical mass

  • MRI

    • visualize point of attachment and differentiate between thrombus and a tumour


Management

MANAGEMENT

  • Resection is required due to risk of embolization or CVS complications


Prognosis

PROGNOSIS

  • Rapid recovery

  • Atrial arrythmias or AV conduction abnormalities may be present

  • Recurrence

  • Echo 5 years to exclude recurrence


Referances

REFERANCES

  • References are available from the author

    • [email protected]


Acknowledgements

ACKNOWLEDGEMENTS

  • Dr. W. Simmons

  • Dr. E.W. Turton

  • Dr. A.M. Ackermann


Thank you for your attention

THANK YOU FOR YOUR ATTENTION


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