Only rarely do myxomas originate from the mitral valve. This is the report of a 49-year-old woman presenting with congestive heart failure. . Rarely do they occur in other areas of the heart and only exceptionally are the valves involved. This is our first case of a myxoma involving the mitral valve and, as far as we know, the 23 rd case reported in the literature. Case ReportA 49-year-old black woman was admitted to the hospital with a history of palpitations on efforts and progressive dyspnea over the previous two years. She reported no other symptoms. She had a history of systemic arterial hypertension for five years and her parents had "cardiac problems". On physical examination she had distended jugular veins at 45 o with increased a wave in the venous jugular pulse. Both the carotid pulse and other arterial pulses were normal. On admission, her blood pressure was 160/120mmHg. Parasternal right ventricular heave was palpable in the lower left parasternal border. An apex impulse with a diameter of less than 2 fingertips was palpable and palpable valvar sounds were present at the apex and at the pulmonic area. Loud S1 and P2, as well as S4 from the RV could be heard. An intense protodiastolic murmur, which was interpreted as a tumor plop, could be heard in the mitral area, where a 2+/6+ proto-meso systolic murmur and a diastolic rumble 3+/6+ were also detected. Lungs were clear and there was mild hepatomegaly, which was not painful on palpation. Lower limbs showed signs of chronic venous insufficiency, with mild bilateral ankle edema.Electrocardiogram showed left atrial enlargement and diffuse abnormalities of the ST-T segments, with flattened T waves. Moderate enlargement of the cardiac silhouette, with left atrial and right ventricular enlargement, and signs of venocapillary pulmonary hypertension were present on chest X-ray. Transthoracic echocardiogram showed a dilated left atrium and a mass could be seen attached to the anterior leaflet of the mitral valve. Transesophageal echocardiogram showed a rounded mass, with regular contours and homogenous appearance, which measured 2.5 x 2.2cm and was attached to the atrial part of the anterior leaflet of the mitral valve ( fig. 1). A peak gradient of 24mmHg and a mean gradient of 14mmHg between the left atrium and ventricle were present. Coronariography showed normal coronaries and a radioluscent mass inside the left atrium projecting itself inside the left ventricle during diastole was seen by ventriculography.The patient underwent surgery with cardiopulmonary bypass 20 days after admission. Left atriotomy showed a purple tumor which measured 2.5 x 3.0cm in its largest diameter, had regular borders and a small peduncle which was attached to the anterior leaflet of the mitral valve in its cephalic and basal portion ( fig. 2). The tumor and its attachment to the mitral valve were excised and a bovine pericardium patch was used to repair the valve. Elongated cells (fusiform) and star-shaped cells in a myxomatous estroma, which are typical of myxomas, were seen by ...
ImportancePlatelet activation is a potential therapeutic target in patients with COVID-19.ObjectiveTo evaluate the effect of P2Y12 inhibition among critically ill patients hospitalized for COVID-19.Design, Setting, and ParticipantsThis international, open-label, adaptive platform, 1:1 randomized clinical trial included critically ill (requiring intensive care–level support) patients hospitalized with COVID-19. Patients were enrolled between February 26, 2021, through June 22, 2022. Enrollment was discontinued on June 22, 2022, by the trial leadership in coordination with the study sponsor given a marked slowing of the enrollment rate of critically ill patients.InterventionParticipants were randomly assigned to receive a P2Y12 inhibitor or no P2Y12 inhibitor (usual care) for 14 days or until hospital discharge, whichever was sooner. Ticagrelor was the preferred P2Y12 inhibitor.Main Outcomes and MeasuresThe primary outcome was organ support–free days, evaluated on an ordinal scale that combined in-hospital death and, for participants who survived to hospital discharge, the number of days free of cardiovascular or respiratory organ support up to day 21 of the index hospitalization. The primary safety outcome was major bleeding, as defined by the International Society on Thrombosis and Hemostasis.ResultsAt the time of trial termination, 949 participants (median [IQR] age, 56 [46-65] years; 603 male [63.5%]) had been randomly assigned, 479 to the P2Y12 inhibitor group and 470 to usual care. In the P2Y12 inhibitor group, ticagrelor was used in 372 participants (78.8%) and clopidogrel in 100 participants (21.2%). The estimated adjusted odds ratio (AOR) for the effect of P2Y12 inhibitor on organ support–free days was 1.07 (95% credible interval, 0.85-1.33). The posterior probability of superiority (defined as an OR > 1.0) was 72.9%. Overall, 354 participants (74.5%) in the P2Y12 inhibitor group and 339 participants (72.4%) in the usual care group survived to hospital discharge (median AOR, 1.15; 95% credible interval, 0.84-1.55; posterior probability of superiority, 80.8%). Major bleeding occurred in 13 participants (2.7%) in the P2Y12 inhibitor group and 13 (2.8%) in the usual care group. The estimated mortality rate at 90 days for the P2Y12 inhibitor group was 25.5% and for the usual care group was 27.0% (adjusted hazard ratio, 0.96; 95% CI, 0.76-1.23; P = .77).Conclusions and RelevanceIn this randomized clinical trial of critically ill participants hospitalized for COVID-19, treatment with a P2Y12 inhibitor did not improve the number of days alive and free of cardiovascular or respiratory organ support. The use of the P2Y12 inhibitor did not increase major bleeding compared with usual care. These data do not support routine use of a P2Y12 inhibitor in critically ill patients hospitalized for COVID-19.Trial RegistrationClinicalTrials.gov Identifier: NCT04505774
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