DISCUSSION
Cardiac tumours are amongst the rare diseases of heart with incidence of
0.02 %. Metastatic tumours are more common to heart as compared to
primary tumours. Median age of presentation is 50 years (1). Atrial
myxoma constitutes about more than 50% of all benign cardiac neoplasms.
75% of all Atrial Myxoma arises from left atrium, with majority
originating at the edge of fossa ovalis, while 15-20% arises from right
atrium; commonly at the edge of fossa ovalis. Bilateral myxoma
represents extension from one atrium to another via foramen ovale. 3-4%
of myxoma arises from ventricle with biventricular extension rarely
seen. Vast majority are sporadic with male: female ratio 1:3. 5-10% are
familial with slight male preponderance and are multicentric and more
likely to recur.(2)
Clinical manifestations are due to location of the myxoma, propensity of
embolization and nonspecific constitutional symptoms elaboration of
cytokines by the tumour. Patient may present with symptoms of left sided
or right sided cardiac failure, depending upon site of mass, point of
obstruction caused by the mass. Valvular masses can cause insufficiency
or relative stenosis of the mass. Left sided mass can embolise to
systemic circulation causing stroke, acute limb ischemia.(3)
Echocardiography is initial modality of choice, with advantage of
temporal as well as spatial resolution the evaluating the motion of
pedunculated tumour in cardiac chamber and its effect on the normal
contraction , valvular function and blood flow during cardiac cycle(6).
ECG gated CT and MRI can provide additional information in terms of
tumour diagnosis, extent and involvement. Treatment is surgical excision
of myxoma with cuff of normal endocardium to decrease chances of
recurrence and it is usually curative. Resulting defect is closed
primarily if possible or with autologous or bovine pericardium.
Prognosis is excellent with expected survival equivalent to general
population. Overall rate of embolization with cardiac tumour is around
25 %, with tumours in let atrium and aortic valve with maximum embolic
potential (4) this is the reason the cases of LA Myxoma should be
operated as soon as possible.
Resection of LA myxoma requires CPB support. Although there are no set
guidelines for commencing cardiopulmonary bypass in cases of Myxoma, The
society of Thoracic Surgeons Clinical Practice Guidelines published in
2011; recommend delaying surgery for Infective Endocarditis complicated
by intra cranial bleed by up to 4 weeks from onset of cerebrovascular
complications, due to the risk of extension of haemorrhage potentially
causing lifelong morbidity or life threatening consequences from
existing site of intracranial bleed.(7) Considering the risks of the
extension of intracranial bleed, the surgery was delayed by 4 weeks in
our patient.