Case Report
A 79-year-old man with a history of hypertension, diabetes, chronic
kidney disease, aplastic anemia, and thrombocytopenic purpura was
admitted to another hospital with severe chest pain. He was diagnosed
with unstable angina, and underwent immediate coronary angiography.
There was a 75% stenosis in the right coronary artery (RCA), and 90%
stenosis in the left anterior descending artery (LAD) and left
circumflex artery (LCX). PCI for LAD and LCX was successfully performed.
Ten hours after the PCI, the patient complained of severe dyspnea.
Echocardiogram revealed that a mass occupied the LA cavity (Figure 1).
The patient was transferred to our hospital for the treatment of left
atrial mass causing acute heart failure.
At presentation, he was hemodynamically stable on dobutamine of 1γand
oxygen (blood pressure 100/60 mmHg, pulse 90 beats/min, and saturation
95%). Echocardiography showed that the mean pressure gradient through
the mitral valve was 8.3 mmHg and estimated systolic pulmonary arterial
pressure was 50 mmHg. Computed tomography (CT) showed a large mass (88
mm × 60 mm) in the LA (Figure 2); however, no contrast effect was seen
in the mass. The patient was diagnosed with acute heart failure due to
the LA mass causing functional mitral stenosis (MS), and underwent
emergent surgery for mass removal.
Under median sternotomy, cardiopulmonary bypass was established with
ascending aortic and bicaval cannulations. After aortic clamping, the
incision of LA was made through the superior transseptal approach.
Inside the LA, tumor was not detected and the endocardium was intact.
However, a remarkable bulging of the entire posterior wall of the LA was
observed and the endocardium of the LA wall was incised. There was a
voluminous clot in the LA wall. After complete evacuation of the clot,
the endocardium of the posterior wall was sewn with 5-0 polypropylene.
Additionally, we performed coronary artery bypass grafting (CABG) for
RCA using a saphenous vein graft. Cardiopulmonary bypass and operation
time was 160 and 279 minutes, respectively.
After the operation, we performed angiography again to detect the cause
of LA IMH. The angiography showed continuous extravasation of contrast
from the terminal LCX (Figure 3), and it was successfully treated with
embolization using two 15 mm coils.
The day after surgery, echocardiography showed the LA IMH (42 × 48 mm),
however, there was no pressure gradient through the mitral valve. In
addition, he remained hemodynamically stable. Because he had to receive
dual antiplatelet therapy (aspirin and clopidogrel) for the stent in the
coronary artery, we decided to pursue a watchful follow-up during
hospitalization. Serial echocardiography showed improving LA IMH (Figure
4). He was discharged on postoperative day 15.
One year after the surgery, CT showed no IMH in the LA (Figure 5).
Informed consent was obtained from the patient regarding the publication
of this case report.