Discussion
The cardiovascular manifestations of patients with left atrial myxoma
strongly depend on tumor size and localization2. The
patient in the present case showed respiratory failure and acute
pulmonary edema as the initial signs, which were probably caused by an
acute enlargement of the myxoma due to an internal hemorrhage.
Unfortunately, the diagnosis of myxoma was overlooked during the initial
evaluation with bedside ultrasound. The probable reason is that
emergency physicians have less training in ultrasonographic image
acquisition and interpretation compared with sonographers or skilled
physicians that are trained in echocardiography. In addition, it is
challenging to differentiate myxomas from valve vegetations and left
atrial clots under severe tachycardia. Therefore, it is important to
consider cardiac myxoma in the differential diagnosis of respiratory
failure and acute pulmonary edema in emergency departments, especially
for those patients without a history of heart disease, as early
consultation with experienced sonologists.
Despite early positive internal medicine treatment, the patient’s
condition rapidly progressed to cardiopulmonary failure. At this time,
it was discovered that the giant
atrial myxoma was the cause and had
to be operated immediately; however, the local hospital was unable to
carry out the operation. As a result, VAV-ECMO was performed as an
alternative intervention. ECMO is a rescue therapy that can stabilize
patients with severe hypotension, with or without respiratory failure.
In cardiology, the main indications for ECMO include cardiac arrest,
cardiogenic shock, post-cardiotomy shock, refractory ventricular
tachycardia, and acute management of complications of invasive
procedures3. The use of ECMO as a bridge between the
transfer and perioperative periods of patients with acute heart failure
in cardiac surgery has been shown to be a viable strategy in the recent
years; however, it is rarely reported for surgical treatment of atrial
myxoma4. Therefore, the case suggests that atrial
myxoma is prone to sudden death, and once diagnosed, it should be
operated as soon as possible under the guidance of ECMO if necessary.