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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
special investigations
SPECIAL INVESTIGATIONS
  • Heartsonar:
    • Mass in left atrium
  • Angiogram:
    • Significant stenosis of 80% on circumflex artery
    • Intermediate lesion on LAD
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
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 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 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 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
acknowledgements
ACKNOWLEDGEMENTS
  • Dr. W. Simmons
  • Dr. E.W. Turton
  • Dr. A.M. Ackermann
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