Case report A giant atrial myxoma with fairly atypical features Aytac Akyol a , HakkıŞimşek a , Mehmet Yaman b, ⁎, Ali Kemal Gur c , Serkan Akdag a a Yuzunci Yil University, Faculty of Medicine, Cardiology Department, Van, Turkey b Samsun Education and Research Hospital, Department of Cardiology, Samsun, Turkey c Yuzunci Yil University, Faculty of Medicine, Cardiovascular Surgery Department, Van, Turkey abstract article info Article history: Received 10 October 2015 Received in revised form 22 November 2015 Accepted 23 November 2015 Available online 15 December 2015 Atrial myxomas are the most common primary heart tumors. Because of nonspecific symptoms, early diagnosis may be a challenge. Most of these are attached to the inter-atrial septum and are mostly asymptomatic but even- tually can cause symptoms depending on the size, mobility, and location of the tumor. We report a case of a large myxoma in the right atrium, which is an uncommon location for this type of tumor. © 2015 The Society of Cardiovascular Academy. Production and hosting by Elsevier B.V. All rights reserved. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: Right atrium Cardiac tumor Giant myxoma Case report A 36-year-old man presented with atypical chest pain and palpita- tions for the last a month. On examination vital signs were as follows: blood pressure 110/70 mmHg, pulse 110 beats/min, and oxygen satura- tion 95% on room air, respiratory rate 18 breaths/min. The cardiovascu- lar examinations revealed regular but tachycardic heartbeat with a diastolic murmur of grade 1–2/6 and also jugular venous congestion. The examination of other systems was normal. The ECG detected sinus tachycardia. A chest X-ray showed clear lung fields with cardiomegaly. Complete blood count and basic biochemical parameters were normal. Sedimentation rate was 11 mm/h, CRP was 3 mg/l. Transthoracic echo- cardiography revealed a mass almost completely fill the right atrium prolapsing through the tricuspid valve into right ventricle (10 × 5 cm di- ameter) (Fig. 1). The left ventricular size and function were normal in echocardiographic examination. Transesophageal echocardiography confirmed this well-circumscribed mass extending from the right atri- um to the right ventricle which caused tricuspid regurgitation and ste- nosis. Transesophageal images could not be recorded due to technical reasons. The patient was referred to cardiovascular surgery. Right atriotomy was applied (Fig. 2). The tumor, originating from the base of the right atrium, was excised from sufficient depth completely (Fig. 3). Resected area was powered with pericardial patch after extrac- tion process. The result of the pathological examination of tumor was compatible with a myxoma of dimensions 7.5 × 4.5 × 4.5 cm. The patient was discharged one week after the surgery without complaint. Discussion This clinical case is quite unusual, considering the massive dimen- sions of the myxoma, the uncommon localization in the right atrium, the rare clinical presentation as atypical chest pain and palpitation, the sex of the patient and the discrepancy between transthoracic echocar- diogram findings and poor clinical presentation. The clinical manifestations usually depend on the anatomic position and size of the mass. There are mainly 3 types of presentations: embolic, obstructive, and constitutional. Embolic manifestations include visceral infarctions, stroke, and myocardial infarction. In a related study evaluat- ing the risk factors for embolism in cardiac myxoma, location of the myxoma and irregular tumor surface were independently associated with increased risk of embolic complications. 1 Obstructive manifestations are usually mistaken for valvular stenosis. For instance, mitral valve obstruction due to left atrial myxoma presents with symptoms such as syncope and dyspnea, mimicking mitral valve stenosis. Although right-sided myxomas are rare, the signs and symptoms of RA myxomas are highly variable, to rely on the size, location, and mobility of the tumor. 2 Right atrial myxomas may remain asymptomatic or cause variable signs and symptoms, for example fever, weight loss, arthralgia, Raynaud's phenomenon, anemia, hypergammaglobulinaemia and elevated erythrocyte sedimentation rate. 2 The symptoms were gone after the tumor is removed. Our patient had fever, arthralgia, and anemia. The most prevent symptoms is dys- pnea (in 80% of patients). Patients may present with right heart failure secondary to right ventricular outflow tract obstruction, or with syncope secondary to temporary complete obstruction of the tricuspid valve. 3 International Journal of the Cardiovascular Academy 2 (2016) 42–43 ⁎ Corresponding author at: Samsun Education and Research Hospital, Department of Cardiology, Ilkadım 55100 Samsun, Turkey. Tel.: +90 533 477 41 46; fax: +90 362 216 83 52. E-mail addresses: dmfakyol@hotmail.com (A. Akyol), hsimsek@gmail.com (H. Şimşek), dr.yaman@windowslive.com (M. Yaman). Peer review under responsibility of The Society of Cardiovascular Academy. http://dx.doi.org/10.1016/j.ijcac.2015.11.005 2405-8181/© 2015 The Society of Cardiovascular Academy. Production and hosting by Elsevier B.V. All rights reserved. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 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