a 76-year - old woman with hypertension was admitted to the hospital with complaints of chest pain and dyspnea .
arterial blood gas analysis revealed the following findings of hypoxemia and hypocapnia : po2 , 36.7 mmhg ; and pco2 , 30.4 mmhg .
the patient 's cardiac enzyme values were : creatine kinase - mb , 105 ng / ml ; and troponin i , 0.38 ng / ml . the b - type nitriuretic peptide test result was 64 .
a diagnosis of recent myocardial infarction was made based on the following electrocardiographic findings : t - wave inversions and q waves in leads ii and iii and a vf , and t - wave inversions in leads v1 to v4 .
transthoracic echocardiography revealed akinesia in the apex free wall of the right ventricle , moderate pulmonary hypertension ( right ventricular systolic pressure [ rvsp ] , 55 mmhg ) , and a 2.72.8 cm mobile mass in the free wall of the right atrium .
pulmonary computed tomography ( ct ) angiography revealed pulmonary emboli occluding the pulmonary arteries in the upper and lower lobes on both sides , and a suspicious intra - atrial cardiac tumor with pulmonary thromboembolism was revealed according to the radiologic findings ( fig .
to detect other possible causes of the pulmonary embolism , abdominal ct and tumor marker tests were performed , the results of which were all normal .
the patient was diagnosed with pulmonary embolism due to the mass in the right atrium based on the result that the patient 's d - dimer was < 0.35 . however , the patient refused surgical treatment .
after 26 months , she was intubated due to severe dyspnea and was then referred to ajou university hospital .
transthoracic echocardiography revealed : 1 ) hypokinesia in the right ventricle , 2 ) a dilated right ventricle , 3 ) mild pulmonary hypertension , 4 ) a 3.52.8 cm mass in the free wall of the right atrium , which had grown compared to previous findings , and 5 ) tricuspid regurgitation .
pulmonary ct angiography revealed emboli occluding the right pulmonary artery and segmental arteries in the upper , middle , and lower lobes with a right atrial mass .
the radiological characteristics were similar to that of a previous study ( an intra - atrial cardiac tumor with pulmonary thromboembolism ) ( fig .
pulmonary perfusion imaging showed decreased perfusion in the majority of the upper and lower right lobes , in part of the anterior segment of the left upper lobe , and in part of the superior and posterior basal segments of the left lower lobe ( fig .
transesophageal echocardiography revealed a 4.82.6 cm hypermobile mass with multilobular heterogeneous echogenicity in the upper lateral aspect of the free wall of the right atrium , which was not affecting the blood flow in the superior vena cava , inferior vena cava , or tricuspid valves ( fig . 2c ,
coronary angiography showed findings of moderate coronary artery disease , which was treated with drug therapy alone .
we decided to perform removal of the right pulmonary arterial emboli and the mass in the right atrium .
the emboli in the left pulmonary artery decreased in size compared to the previous ct findings , and it was not considered a critical lesion because it was confined to the inferior lingular segmental artery . a standard sternotomy incision was made .
the patient 's body temperature was lowered to 23 ( moderate hypothermia ) through cardiopulmonary bypass , and then the myxoma with a 2 to 3 mm pedicle on the free wall of the right atrium was excised along with adjacent normal tissue . at 23 , we opened the right pulmonary artery , which revealed that the myxoma segment was not adhered to the intima of the artery ( fig .
an embolus within the right pulmonary artery was removed en bloc in a bloodless surgical field ( fig .
3b ) . after we confirmed that there were no further masses in the arteries supplying each segment , the right pulmonary artery and atrium were closed .
histopathological examination revealed that both the mass resected from the right atrium ( 4.33.53 cm ) ( fig .
3c , white arrow ) and the embolus removed from the right pulmonary artery ( 721.5 cm ) ( fig .
in addition , the size of the right atrium had decreased and the pulmonary artery pressure had slightly decreased to 35 mmhg . however , tricuspid regurgitation remained stationary ( grade 2/4 ) .
imaging studies , the right lung had improved , but the left lung showed no changes .
the patient is currently on out - patient follow - up without any significant symptoms . according to the echocardiography performed in december 2010
, there was no evidence of pulmonary embolism , and the rvsp was 35 mmhg .
pulmonary emboli are mainly caused by deep vein thromboses and embolus in the right heart or at the tip of a catheter .
chitwood   were the first to perform a successful resection of a myxoma through cardiopulmonary bypass .
the recurrence rate of pulmonary embolism after resection has been reported to be 0.4% to 5% .
pulmonary emboli frequently recur when 1 ) surgical resection is incomplete , 2 ) emboli detached during surgery adhere to the intima of the heart , 3 ) emboli are of multicentric origin , 4 ) there is a family history of myxoma , or 5 ) a new myxoma develops from myxoma precursor cells . because myxoma tissue is extremely friable , it is frequently detached and it adheres to a new site [ 2 - 5 ] .
approximately 75% of all the myxoma cases occur in the left atrium , 23% in the right atrium , and 2% in the ventricle .
myxoma can manifest obstruction symptoms due to blood flow blockade , symptoms due to embolism , arrhythmia , and other generalized symptoms .
syncope or sudden death can develop when pulmonary or systemic circulation is disturbed or when blood flow to the atrioventricular valve is blocked .
thrombosis can be induced by myxoma segments , thrombi that has formed within the tumor , or infected lesions within the tumor .
embolism occurs in 30% to 45% of the patients with myxoma of the left atrium .
emboli originating from myxoma in left atrium are mainly found in the brain , kidney , and branches of the aorta and lower extremities .
embolism occurs in approximately 10% of the patients with myxoma in the right atrium , and even pulmonary embolism can occur as in our case . in our case ,
the pulmonary embolism that had been diagnosed in may 2008 was different from the one detected by pulmonary ct angiography in march 2006 .
the former is thought to have been induced by thrombi formed by the myxoma in the right atrium , but not by myxoma segments , because the ct density ( region of interest [ roi ] property ) was significantly higher in the myxoma detected in may 2008 ( roi , -20 for the myxoma in the right atrium as well as for the myxoma in the right pulmonary artery ) than in the myxoma detected in march 2006 ( roi , 80 ) . in march 2006 , heparin administration at admission and maintenance anticoagulant therapy with coumadin resolved thrombi in the pulmonary artery on both sides were performed ; however , in may 2008 , the myxoma mass in the right atrium was separated and occluded the right pulmonary artery , causing severe dyspnea that required endotracheal intubation .
removal of myxoma in the right side is important for preventing pulmonary embolism , maintaining contractibility , and restoring dilation functions of bilateral atria .
special precautions should be taken during tumor resection in order to prevent thrombus formation and pulmonary embolism .
jones et al .   proposed that complete resection of myxoma should be performed under adequate exposure and minimal manipulation . furthermore
, pulmonary embolectomy should be considered in cases of myxoma associated with pulmonary embolism in order to improve patient symptoms .
we reported a case of a 76-year - old woman with myxoma in the free wall of the right atrium .
the patient 's initial bilateral pulmonary embolism was developed due to thrombi formed by the myxoma ; however , the embolism that occurred again two years later was due to myxoma segments .
 a 76-year - old woman with hypertension was admitted to the hospital with complaints of chest pain and dyspnea . 
 an echocardiogram and pulmonary computed tomography angiography showed right atrial myxoma complicated with pulmonary thromboembolism . an operation to resect the right atrial myxoma and pulmonary embolism was recommended ; however , the patient refused and was discharged with anticoagulation therapy . 
 two years later , she developed dyspnea . 
 radiological studies and echocardiography showed similar results with the previous findings . 
 the patient underwent mediastinotomy with resection of the right atrial myxoma and pulmonary embolectomy . 
 as there are few reports on right atrial myxoma complicated with pulmonary embolism , we report a successful case of surgical removal of right atrial myxoma and pulmonary embolism . 