Case presentation
A 61-year-old woman was admitted to our hospital for symptomatic and drug-resistant paroxysmal atrial fibrillation (PAF) to undergo pulmonary vein isolation (PVI). She had no significant past medical history. Transthoracic echocardiography (TTE) showed no cardiac structural abnormalities with a small left atrium (LA) (LA diameter, 34 mm). CHADS2-Vasc score was 1 point (female sex), showing a low thromboembolic risk under optimal oral anticoagulant therapy, and she had taken rivaroxaban for more than 3 weeks. She had a negative COVID-19 test result, but we decided to use an intra-procedural intracardiac echocardiography (ICE) to evaluate left atrial appendage (LAA) for anatomy and thrombus, as an alternative to pre-procedural transesophageal echocardiography (TOE) and cardiac computed tomography (CT). Because, there is almost no risk of thrombus in patients with PAF under optimal anticoagulation whose CHADS2-Vasc score is 1. Before the transseptal puncture, ICE depicted an LA mass attached to the atrial septum, measuring around 15 mm in diameter (Figure 1 ), and the procedure was discontinued. TOE reveled vascular flow in the stemless mass, which was 1.7 cm in diameter, and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET/CT) showed low-level FDG accumulation with a maximum standardized uptake value of 4.4, and therefore LA myxoma was suspected. Surgical resection of the intracardiac tumor together with concomitant surgical PVI was performed, and the histological diagnosis was cardiac myxoma.