Atrial myxoma in early pregnancy

Abstract

Atrial myxoma is the most common primary cardiac tumour with a prevalence of 0.075% with a mean age for sporadic cases of 56 years. We report the case of a 30 year old primigravida who presented at 6+5 weeks pregnant with worsening dyspnoea and palpitations. Cardiac echo revealed a large left sided atrial myxoma causing outflow obstruction and mitral valve damage. The primary excision surgery required 84 minutes of cardiopulmonary bypass, and whilst successful, follow-up transthoracic echo revealed significant mitral valve regurgitation requiring valve replacement. This was performed with a bioprosthetic valve with 105 minutes of cardiopulmonary bypass. Post-operatively she remained in a pacing dependent rhythm and so had a permanent pacemaker sited. The first trimester was complicated with recurrent episodes of vaginal bleeding thought to be related to the heparin given at time of bypass. Routine anomaly ultrasound at 20 weeks gestation revealed a normal fetus but mild polyhydramnios and subsequent glucose tolerance testing found her to have gestational diabetes which was controlled with dietary measures. She was induced at 42 weeks gestation for post-maturity and had an emergency caesarean section for fetal distress. We report this case for its rarity – not only for the underlying disease process but for a successful pregnancy outcome following 2 prolonged periods of cardiopulmonary bypass in early pregnancy.

Cardiac myxoma in pregnancy: a comprehensive review

“…Location of cardiac myxoma was not clearly stated in 5 (9.8%) patients. In the remaining 46 (90.2%) patients, it was located in the left atrium in 37 (80.4%) [intraatrial septum in 11 (29.7%) [ 8 - 10 , 26 , 29 , 30 , 40 , 42 , 47 , 48 ] , anterior mitral leaflet in 2 (5.4%) [ 2 , 32 ] , free wall [ 36 ] in 1 (2.7%) and unknown in 23 (62.2%) patients [ 2 , 13 , 14 , 16 - 18 , 23 , 24 , 26 - 28 , 31 , 33 , 34 , 37 - 39 , 44 - 46 , 50 ] , right atrium in 5 (10.9%) [ 2 , 11 , 15 , 20 , 36 ] (one was multiple [ 20 ] ), left ventricle in 2 (4.3%) [ 12 , 21 ] , right ventricle in 1 (2.2%) [ 43 ] and multiple sites (septal tricuspid leaflet, left atrium, intraatrial septum and left atrial appendage) in 1 (2.2%) patient [ 41 ] . Three patients had recurrent cardiac myxomas [ 12 , 35 , 41 ] and one of them were recurrent multiple cardiac myxomas [ 41 ] .…”

“…Concerning the remaining 49 patients, surgical operation was not performed in 2 (4.1%) patients but with anticoagulant and antibiotic therapy in one [ 36 ] and decline of treatment by another [ 41 ] . A surgical resection of cardiac myxoma was performed in 47 (95.9%) patients including a sole cardiac myxoma resection in 41 (87.2%) [ 2 , 8 - 21 , 23 - 27 , 29 , 31 - 39 , 43 - 46 , 48 - 50 ] , concurrent mitral valve repair [ 40 , 47 ] and staged mitral valve replacement [ 28 , 29 ] in 2 (4.3%), and staged mitral valve repair [ 30 ] and concurrent patent fossa ovalis closure [ 42 ] in 1 (2.1%) patient. Cardiac surgery was performed in the first, second and third trimester in 5 (13.9%), 14 (38.9%) and 17 (47.2%) patients ( χ 2 =9.8, P =0.008) at a mean of 25.2±9.4 (range, 9-41; median 27) weeks of gestational age ( n =36); while timing of cardiac surgery was not given in 15 (29.4%) patients.…”

“…Voluntary termination of pregnancy was done in 7 (13.7%) cases with 6 (85.7%) early-mid-termed [ 2 , 9 , 12 , 23 , 42 ] and 1 (14.3%) late pregnancy termination [ 50 ] with mean gestational age of 17.0±8.3 (range, 11-31; median, 14) weeks ( n =5). Delivery modes of remaining 31 (60.8%) pregnant patients were cesarean section in 19 (61.3%) [ 2 , 10 , 11 , 13 , 16 , 20 , 21 , 28 - 30 , 32 , 35 , 36 , 39 , 40 , 43 , 45 , 46 ] , vaginal delivery in 6 (19.4%) [ 8 , 25 , 26 , 48 , 49 ] , forceps under epidural analgesia in 1 (3.2%) [ 33 ] and unknown in 5 (16.1%) patients [ 14 , 17 - 19 , 34 ] . One (3.2%) delivery timing was not given, 2 (6.5%) deliveries were in second trimester and 28 (90.3%) in third trimester with mean gestational age of 35.3±4.6 (range, 22-42; median, 37) weeks ( n =30).…”

“…The prognosis of the pregnant patient was not given in 2 patients [ 22 ] . In the remaining 42 pregnant patients with a childbirth, 35 (83.3%) were event-free, 6 (14.3%) were complicated, with cerebral involvement (psychomotor agitation and mydriasis anisocoria) [ 40 ] , heart block [ 30 ] , pacing dependent rhythm [ 28 ] , pulmonary edema [ 32 ] , uterine contractions [ 26 ] , and premature labor [ 34 ] ), and 1 (2.4%) was recurrent (requiring reoperation) [ 29 ] . No pregnant patients died.…”