European Journal of Echocardiography Advance Access originally published online on March 11, 2008
European Journal of Echocardiography 2008 9(3):415-416; doi:10.1093/ejechocard/jen023
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Ockham's razor or Hickam's dictum: a right atrial mass following excision of left atrial myxoma
Yigal Abramowitz1,*,
Gidon Perlman1,
Eli Levy2,
Ronen Beeri3,
Tova Chajek-Shaul1 and
David Leibowitz1
1 Department of Internal Medicine, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem 91240, Israel
2 Department of Cardio-Thoracic Surgery, Hadassah-Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel
3 Department of Cardiology, Hadassah-Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel
Received 3 November 2007; accepted after revision 18 November 2007; online publish-ahead-of-print 11 March 2008.
* Corresponding author. Tel: +972 2 5844520; fax: +972 2 5812754. E-mail address: yigalab{at}yahoo.com
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Abstract
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We report a case of a 54-year-old man presenting with a right
atrial mass 7 months after undergoing a left atrial myxoma excision
surgery. The differential diagnosis included recurrent myxoma
or thrombus. The patient underwent repeat open sternotomy on
cardiopulmonary bypass. Histopathological evaluation of the
mass revealed an organizing thrombus. This report is, to our
knowledge, the first that demonstrates right atrial thrombus
shortly following excision of left atrial myxoma.
Keywords: Atrial myxoma; Thrombus; Excision; Atrial mass
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Case report
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A 54-year-old man presented to our hospital with an episode
of syncope on exertion. During the 6 weeks prior to admission
he suffered from progressive exertional dyspnea. On physical
examination, a 2/6 systolic murmur was heard at the left sternal
border, with a fixed split S2. ECG and chest X-ray were unremarkable,
and the patient was admitted for further evaluation. Transthoracic
echocardiography revealed a large pedunculated mobile mass measuring
44
x 55 mm, attached to the interatrial septum with prolapse
into the left ventricular cavity during diastole (
Figure 1).
This finding was consistent with a large left atrial myxoma.
Transesophageal echocardiography performed prior to surgical
excision revealed a multilobulated left atrial mass protruding
into the left ventricle cavity and creating a sub-total obstruction
of the mitral valve in diastole (
Figures 2 and
3). A fully
animated version of
Figures 2 and
3 can be viewed in the
Supplementary material (Movies I and II). The mass was removed
via open sternotomy on cardiopulmonary bypass (
Figure 4)
and histology was consistent with the diagnosis of myxoma.
Seven months later, the patient underwent a routine transthoracic
echo as follow-up after removal of the myxoma, which revealed
a mobile echodensity in the body of the right atrium. Transesophageal
echocardiography was performed and revealed a pedunculated mobile
mass measuring 31
x 44 mm, attached near the entrance of the
inferior vena-cava and extending to the body of the right atrium
(
Figure 5, Supplementary material online, Movie III). The
differential diagnosis included recurrent myxoma or thrombus.
The patient was treated with anticoagulation for 3 months. Repeat
transesophageal echocardiography was performed and demonstrated
no change in the right atrial mass. Owing to the clinical suspicion
of recurrent myxoma, the patient underwent repeat open sternotomy
on cardiopulmonary bypass. Histopathological evaluation of the
mass revealed an organizing thrombus.
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Discussion
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This report is, to our knowledge, the first that demonstrates
right atrial thrombus shortly following excision of left atrial
myxoma. Cardiac myxomas usually occur sporadically, but recurrent
cases have been described from as soon as few months to as long
as 8 years after excision of the myxoma with reported recurrence
rate ranging from 5 to 14%.
1 Thrombus formation in the right
atrium after cardiac surgery is extremely unusual and presumably
because of local factors related to cannulation of the right
atrium during cardiopulmonary bypass.
2 While the principle of
diagnostic parsimony as exemplified by Ockham's razor, a principle
attributed to William of Ockham (fourteenth century) stating
‘entities should not be multiplied beyond necessity’,
supported a diagnosis of recurrent myxoma in this case, the
final diagnosis of thrombus supports Hickam's dictum, a principle
attributed to Dr John Hickam (twenty-first century) stating
‘Patients can have as many diseases as they damn well
please’, that the patient can have as many illnesses as
he pleases. The diagnosis of atrial thrombus should be considered
in patients with right atrial masses following myxoma excision.
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Supplementary material
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Supplementary material associated with this article can be found in the online version.
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References
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- Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Medicine (Baltimore) (2001) 80:159–72.[CrossRef][Medline]
- Hyman RL, Karalis DG, Ross JJ, Victor MF, Morris R. Pulmonary embolism from in situ right atrial thrombus after coronary artery bypass surgery. J Am Soc Echocardiogr (1997) 10:760–2.[CrossRef][Web of Science][Medline]
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