P171 Catastrophic systemic multiple embolism from a giant atrial mixoma: a case report
Authors: Cocco D , Gonzalez-Vargas T , Valentino L , Cossa S , Matta G , Manieli C , Locci G , Tocco S , Cirio E M 
Published: January 2020

Atrial mixoma represents the most common cardiac tumour. The diagnosis is usually accidental since it is benign and usually asymptomatic. Nevertheless, life-threathening complications such as embolization may seldom occur. In these cases emergent multispecialistic approach is deemed. We describe the case of a 46 year old man without cardiovascular risk factors and whose previous clinical history was not significant. At home, the patient abruptly presented a right hemiplegia, deviation of the buccal commissure to the left and loss of consciousness. On arrival at the emergency department GCS was 5. Routine blood tests, gas analysis and ECG were unremarkable. An urgent CT scan showed a left fronto-parietal subarachnoid hemmorhage. Soon after admission in the stroke unit the patient showed sign of acute limb ischaemia. A high-resolution 3D-angio CT revealed multiple bilateral renal and splenic infarcts and a massive thrombosis of the abdominal aorta below the renal bifurcation, with extensive involvement of the iliac arteries. Unexpectedly, a bulky mass (max diameter 8 cm) was detected in the left atrium. Transthoracic echocardiography confirmed the presence of an irregularly oval (8x3cm) mobile peduncolate mass with fringed edges, suspected for mixoma, with phasic impingement of the mitral valve and protrusion into the left ventricle. Considering the age of the patient and the very early presentation, after Heart Team discussion the patient underwent an urgent embolectomy with Fogarty catheter followed by cardiac surgery for myxoma resection. After full sternotomy, with an interatrial groove approach, a large tumor with myxoid appearance implanted in the left atrial roof was discovered (8 cm maximum diameter). A complete excision of the mass was successfully performed. The macroscopic examination revealed a tumor with a gelatinous and friable surface, very irregular edges and narrow base of implantation, suggestive of atrial myxoma. The day after a CT revealed multiple new ischemic and hemorragic lesions in the left frontal and parietal lobes, in the right occipital lobes, in the cerebellar emispheres, thalamus and hypotalamus and in the mesencephalus. Multiple thrombosis of the main branches of the Willis polygon were detected as well.

The patient remained comatous (GCS 3) with bilateral midriasis and was intubated in the intensive care unit. The anatomopathological study confirmed the diagnosis of atrial myxoma. Despite the general belief that atrial mixoma present a benign course, clinicians should carefully consider the possibility of dramatic complications, due to the risk of embolization. High resolution imaging techniques are of pivotal relevance for the diagnosis of the tumor and the complications, in which case emergent surgery may be required. Early surgery could be considered in asymptomatic patients because the evolutionary course and the prognosis can unexpectedly be ominous.

Abstract P171 Figure. Multiple embolism from atrial myxoma