An unusual marrow transplant complication: cardiac myxoma

Abstract

Summary:We report a right atrial myxoma which suddenly developed in a thalassemic patient after allogeneic bone marrow transplantation. The tumor was first detected by echocardiography on day +47 after transplant and the patient underwent surgical removal of the myxoma on day +103. The post-operative course was uneventful, and at more than 3 years from the event, he is alive and well, cured from his congenital disease, with no detectable intra-cardiac tumor. The onset of the myxoma in the early post-transplant period and the extremely high velocity of growth suggest a possible relationship of this condition with the immunosuppressive status. Keywords: myxoma; BMT; thalassemia Bone marrow transplantation (BMT) is a situation which may allow the development of rare and sometimes unrecognised complications 1,2 due to the conditioning regimen, immunosuppression, graft-versus-host disease (GVHD) etc. Cardiac myxoma is a rare form of heart tumor whose origin is still under discussion. 3,4 Here, we report the occurrence of a right atrial myxoma in a young thalassemic patient in the early period after BMT. Case reportThe patient was a 17-year-old male suffering from homozygous B thalassemia, referred to our Unit in August 1994 to be evaluated for allogeneic BMT. Following the Pesaro classification system 5 he was evaluated as a class 3 patient. A complete clinical and echocardiographic evaluation was performed before the transplant; twice in his home town and once in Pesaro. Diagnostic conclusions were consistent between the three different cardiologists and showed mild left ventricle dilatation (5.3 cm) with normal myocardial wall thickness and normal regional and global systolic function. No morphological abnormalities were observed in the right heart. The patient underwent BMT on 1 September 1994 from his HLA-identical brother. Preparation for BMT was performed following the scheme at that time in use for class 3 patients 6 (busulfan 14 mg/kg over 4 consecutive days followed by cyclophosphamide 120 mg/kg over 4 days and anti-lymphocytic globulin 2 ml/kg from day −8 to day −2). The early post-BMT course was uneventful and the patient was discharged on day +16 with documented allogeneic engraftment. Because of severe metabolic problems (fasting serum glucose: 44 mmol/l, serum triglycerides: 33 mmol/l) he was readmitted to the ward on day +34. During hospitalization he experienced two episodes of symptomatic hypotension (blood pressure 80/40 mm Hg). Echocardiographic examination performed on 18 October (day +47) revealed 'a large intra-cardiac tumor (oval in shape with maximum diameter = 3.1 cm) with ultrasound density similar to the myocardium, immotile, attached to the lateral wall of the right atrium, below the tricuspid anulus, near to the apex of the central venous catheter, without doppler findings of valve orifice stenosis' (Figure 1). After initial anticoagulant treatment, a MRI scan (Figure 2) was performed (27 October, day +56) which confirmed the presence of tumor, excluded a thrombotic origin, but did not pe...

The Challenge Presented by Right Atrial Myxoma

“…As confirmed by serial echocardiography and repeated surgical excision, both initial [13,28,69] and recurrent atrial myxomas evidently grow particularly rapidly: estimate of average growth is 1.8 cm and 14 g per year [48]. A possible relationship has been suggested between sudden onset of a right atrial myxoma with rapid growth and the immunosuppressive status after allogeneic bone marrow transplantation [6].…”

Myxoma of Donor Origin in a Transplanted Heart

“…15 Another case of atrial myxoma was reported after bone marrow transplantation. 16 Surgical extirpation is the treatment of choice for this condition. The risk associated with this procedure is relatively low, but some complications can occur.…”

Left atrial myxoma in transplanted heart

“…1 There is one report of a patient developing an atrial myxoma after bone marrow transplantation. 2 Atrial myxomas are more common in women; 10% are familial and usually present between the third and sixth decades of life. Serious complications of atrial myxomas include embolisation and mitral valve obstruction.…”