Management of Maternal Atrial Myxoma in Advanced Pregnancy: A Clinical Dilemma

Abstract

1ed term vaginal deliveries. Thus far she had an uneventful pregnancy, and her only significant finding was BMI of 35 and iron deficiency anemia.On admission, the patient was asymptomatic and vital signs revealed blood pressure of 135/80 mmHg, heart rate of 87 bpm, and oxygen saturation of 98% on room air. Laboratory analysis was unremarkable, except for hemoglobin level of 98 g/L. Electrocardiogram showed normal sinus rhythm. TTE confirmed a 4 × 1 cm mobile echo-dense mass arising from interatrial septum (LA side), and prolapsing through the mitral valve during diastole ( Figure 1a and Figure 1b). The left ventricular ejection fraction (67%) and valvular function were normal. Non-stress test confirmed a reassuring fetal status in a cephalic presentation. Following discussion between cardiologists, cardiothoracic surgeons, obstetricians and anaesthetist, consensus decision was made to perform caesarean section first, with a view to proceed with cardiac surgery the following day after stabilizing the patient. She underwent an uncomplicated caesarean section with tubal ligation under general anesthesia, combined with Transesophageal Echocardiography (TEE) (Figure 2), and gave birth to a male infant, weighing 3.670 g with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Hemi-sternotomy was employed and 30,000 Units of IV heparin was administered prior to her heart put on Cardiopulmonary Bypass (CPB) machine. A left atrial mass was resected from the interatrial septum and the defect in the septum was approximated with a patch. The CPB time was 59 minutes. The *Corresponding author: Yaniv Zipori, MD, Department of Obstetrics and Gynecology, Townsville Hospital, Townsville, Queensland 4814, Australia, Tel: +61-7-44333625, Fax: +61-7-44331471, E-mail: zipori74@hotmail.com AbstractIn this report, we present a challenging case of pedunculated left atrial myxoma which was initially diagnosed on Transthoracic Echocardiography (TTE) at 39 weeks and 2 days gestation in a grand-multigravida woman with previous normal deliveries. She was delivered by urgent caesarean section with resection of the myxoma on the following day. She had an unremarkable recovery. Physicians should be vigilant to any new onset maternal heart murmurs during pregnancy, and have a low threshold to screen with transthoracic echocardiography. A multidisciplinary team approach from anesthetists, cardiologists, cardiothoracic surgeons and maternal-fetal medicine specialists is essential to optimize fetal and maternal outcomes.