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.