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CASE REPORT
Year : 2022 | Volume
: 32
| Issue : 3 | Page : 183-184
Dramatic massive arterial embolization from a left atrial myxoma in a patient with takotsubo syndrome
Davide Ermacora1, Andrea Comunello1, Tommaso Gorgatti2, Carmen Ladurner1, Roberto Cemin1
1 Department of Cardiology, Bolzano Hospital, Bolzano, Italy
2 Department of Radiology, Bolzano Hospital, Bolzano, Italy
Correspondence Address:
Davide Ermacora
Department of Cardiology, Bolzano Hospital, Via Lorenz Böhler 5, 39100, Bolzano
Italy
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jcecho.jcecho_22_22
A 52-year-old woman with no cardiovascular risk factors was admitted to our emergency department because of acute limb pain because of arterial ischemia. An urgent angio-computed tomography (CT) scan described acute occlusion of left common iliac artery [Figure 1]a, with a fragment of embolus wedged on the iliac carrefour [Figure 1]b, occlusions of right popliteal artery [Figure 1]c and right internal iliac artery [Figure 1]d, sub-occlusion of superior mesenteric artery at its bifurcation, and diffused ischemic lesions in both kidneys [Figure 1]e and spleen. A CT scan of the brain also revealed small bilateral multiple ischemic injuries. Shortly after admission, the patient developed acute lung edema and a transthoracic echocardiogram showed severe left ventricular dysfunction due to apical ballooning. The diagnosis of takotsubo syndrome was confirmed with a coronary angiogram, which excluded epicardial coronary artery disease or coronary embolic lesions and was supported also by diffuse deep negative T-waves on the electrocardiogram without relevant increase of cardiac enzymes. A transesophageal echocardiogram was able to reveal an 11 mm × 3 mm mass in the left atrium, attached to the interatrial septum next to the posteromedial commissure of mitral valve [[Figure 1]f and [Figure 1]g and Video 1]. It was heterogeneously iso-hyperechogenic, pedunculated and had a high diastolic motion with protrusion through the atrioventricular plane. No intraventricular thrombosis was evident [Video 2]. The patient underwent urgent vascular and heart surgery and histologic analysis on the specimens from both arterial emboli and cardiac mass confirmed their myxomatous nature. In conclusion, this case emphasizes the potential malignancy of left-sided myxomas in terms of embolic complications and underlines the fundamental role of transesophageal echocardiography in identifying the correct source of embolism, particularly in the presence of confounding factors, such as in this case a Takotsubo syndrome, whose onset was a consequence of the massive embolization itself.
Figure 1: (a) MPR CT view (coronal plane) showing the proximal occlusion of left common iliac artery and its distal revascularization through collateral vessels. (b) MPR CT (coronal plane) showing a fragment of embolized myxoma wedged on the iliac carrefour. (c) MPR CT (sagittal plane) showing the occlusion of right popliteal artery right beneath the plane of the knee joint. (d) Axial CT view revealing the occlusion of right internal iliac artery (red arrow). (e) Axial CT view revealing multiple ischemic areas in both kidneys. (f and g) Off-axis 72° TEE view showing a highly mobile left atrial myxomatous mass attached to the cranial portion of interatrial septum next to the anterior leaflet of the mitral valve, pedunculated and protruding in diastole through the mitral annulus (yellow arrow). MPR: Multi-planar reconstruction, CT: Computed tomography, TEE: Transesophageal echocardiographyDeclaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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