A 54-year-old female, a known case of rheumatic heart disease with severe mitral stenosis, MV area was 0.9 cm2, and moderate mitral regurgitation, was admitted to our hospital. The MV and subvalvular apparatus were calcified and there was moderate pulmonary arterial hypertension. Bilateral ventricular functions were within normal limits. She was posted for MV replacement (MVR) and informed consent was obtained. Her preoperative hematological investigations were within normal limits. General anesthesia was induced with standard medications and cardiopulmonary bypass (CPB) was established.\nShe underwent MVR with bioprosthetic valve 25 mm (EPIC, St. Jude Medical). Immediate post-CPB TEE showed normal functioning prosthetic valve and Doppler also revealed normal pressure gradients across the valve []. Her intraoperative period was uneventful and shifted to postoperative Intensive Care Unit (ICU) with minimal doses of inotropes. Postoperative day (POD) 0 was uneventful; however, on POD 1, she developed hypotension (arterial pressure 84/50 mmHg) that required increasing doses of inotropic support. Her central venous pressure was 20 mmHg and pulmonary artery pressure was 60/38 mmHg. Arterial blood gases also revealed metabolic acidosis. Due to her hemodynamic status, she could not be weaned off the mechanical ventilation.\nTEE was done to rule out cardiac tamponade and to evaluate the prosthetic MV function. It revealed a large cavitatory mass occupying the whole of left atrium (LA) which was obliterating the movement of MV leaflets [ and ]. Continuous wave Doppler (CWD) showed pressure gradient (peak/mean) of 19/10 mmHg across MV []. However, bilateral ventricular functions were within normal limits.\nOwing to her deteriorating hemodynamic condition, she was immediately shifted to the operating room. Chest was reopened and CPB was established. Opening of LA revealed dissection of the LA wall extending from the posterior annulus of the MV to the roof of LA. Clots were removed from the LA; however, the cavity again filled up. Therefore, it was decided to do the “marsupialization” for clearing of the cavity [ and ]. The bioprosthetic valve was also examined and was found to be normal. CWD also revealed normal gradient across prosthetic MV []. The patient was weaned off the CPB with low dose of inotropes. She was mechanically ventilated for 24 h and inotropes were gradually weaned off. She had longer stay in the ICU; otherwise her postoperative period was uneventful.
A 51-year-old female presented with a LA mass suggesting myxoma detected by transthoracic echocardiography (TTE) incidentally during a routine check-up. Her past medical history was unremarkable. Her vital sign was stable and blood examinations showed no abnormalities. Her initial electrocardiogram showed normal sinus rhythm without any significant ST-T change, and chest X-ray revealed nothing abnormal. On preoperative TEE, there was a cystic mass (1.7 × 1.3 cm-sized) that was attached to the atrial septum in the LA, without any evidence of valvular insufficiency or stenosis. Similar findings were observed in thoraco-abdominal computed tomography angiography.\nMinimal invasive surgery was planned on patient request and thus incision through right 4th anterior thoracotomy under total cardiopulmonary bypass (CPB) was performed, and myocardial protection was achieved using anterograde cardioplegia. About 1.5 cm-sized yellowish gray mass with cystic cavity was successfully removed from the LA septum, and then inter-atrial septum and right atrium were directly closed without using any prosthetic materials. Weaning of CPB went smoothly, and the postoperative clinical conditions were stable and uneventful without hemodynamic compromise. Pathological review confirmed that the mass removed was cardiac myxoma.\nOn postoperative day 4, TTE was performed to look into her overall postoperative condition, and unexpectedly a new large mass occupying the entire LA was found (). It minimally increased transmitral pressure gradient. Follow-up thoraco-abdominal CT angiographic findings were in line with that found on TTE (). Since newly detected LA mass on CT had 60 Hounsfield units, it was hard to identify what the mass was. It only gave us little information on the real nature of the mass, thrombus versus recent bleeding. For the diagnostic confirmation, thus, CMR was undergone, and showed a 5.4 × 4.4 × 4.0 cm-sized ovoid mass adjacent to the posterior and inferior wall of LA with obtuse angle. It was covered by fibrous smooth wall, meaning intramural rather than intra-atrial condition. Gadolinium enhancement was not observed on early post-contrast T1-weighted images. The mass showed low signal intensity on long-time interval delayed enhancement sequence, and displayed intermediate signal intensity on T1-weighted images and a high signal intensity on T2-weighted images, highly suggestive of acute hematoma, rather than recent bleeding (). Since her vital sign was stable and she was totally asymptomatic, conservative management and close medical follow-up were recommended without additional invasive procedures, and then after a few days of monitoring, she was uneventfully discharged on the post-operative day 8. She has been doing well after discharge, and any other complication was not observed on regular exam. The size of LA intramural hematoma was getting smaller and transmitral pressure gradient decreased on TTE which was performed on the postoperative day 50 (). CMR performed 5 months after index operation demonstrated that LA intramural hematoma finally disappeared ().