2 Case report
A 70-year- old female with past medical history of hypertension and well-controlled diabetes mellitus was evaluated for chest pain and shortness of breath during the last year. Her physical examination was unremarkable with no cardiac murmurs or jugular venous distension. Echocardiography revealed normal systolic left ventricular function and the presence of mobile mass in the right atrium (Fig. 1A).Transesophageal echocardiography revealed a mobile mass in the right atrium, attached to the base of the septal leaflet of the tricuspid valve with no evidence for tricuspid valve regurgitation(Fig.1B). Chest computerized tomography showed a 1 cm mass in the right atrium with no extension to the vena cava (Fig. 1C).Differential diagnosis included right atrial myxoma vs. right sided papillary fibroelastoma. After discussion with the cardiac surgery team, a decision for mass excision was taken. Coronary angiogram before the surgery showed patent coronary arteries with no obstructive disease(Fig. 2). The patient was referred for cardiac surgery, and 1 cm mass was resected from the right atrium (Fig. 3) , with no complications during the surgery or the post-operative course. She was discharged five days later in good clinical condition with no signs of heart failure. Three weeks later, the patient was admitted with weakness, agitation, tachycardia 100 beats per minutes and blood pressure of 70/30 mmHg with diffuse ST segment changes in the ECG (Fig. 4A). The patient was started on intravenous noradrenaline and fluids, without any hemodynamic improvement. Echocardiography revealed severe apical ballooning with left ventricle outflow obstruction (Fig.4B). TTS was highly suspected based on the typical echocardiographic appearance and the normal coronary angiography three weeks earlier. Noradrenaline was hold and she was treated with beta-blockers, however, without any clinical or hemodynamic response. The patient died one hour after admission.