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 ().
A 69-year-old man was admitted in our hospital due to fever, chill, orthopnea and paroxysmal nocturnal dyspnea. In physical examination, respiratory sounds were reduced in both his lower half of lung fields.\nHe had undergone a major cardiac surgery including CABG, MVR, aortic valve replacement (AVR) and ascending aorta replacement due to severe coronary artery disease, significant valvular heart disease (rheumatic) and aneurysmally dilated ascending aorta, 75 days prior to his recent admission.\nAn electrocardiogram revealed atrial fibrillation rhythm, normal axis and non-specific ST-T changes in inferior and lateral leads (). The posteroanterior view of the chest radiography showed massive bilateral pleural effusion. Transthoracic echocardiography followed by TEE showed normal LV size with preserved systolic function, bioprosthetic MV with acceptable hemodynamic and mobility and no paravalvular regurgitation. Bioprosthetic AV had acceptable hemodynamic and mobility without paravalvular regurgitation. There was normal functioning ascending aorta Dacron tube graft without leakage from proximal and distal part of prosthesis.\nThe LA was enlarged and dissection was found on the posterior wall. Two homogenous particles (1.18 × 0.4 cm and 0.9 × 0.58 cm) were attached to the dissecting flaps which were highly suggestive for vegetations and IE (, , and , , , and ).\nLaboratory tests showed severe coagulopathy, high levels of fibrin degradation products, leukocytosis (white blood cells count: 26700/cm3, predominantly poly morphonucleated), severe anemia, thrombocytopenia, elevated liver enzymes and serum creatinine levels. These data were suggestive for DIC. The blood culture revealed enterococci septicemia.\nHis general condition deteriorated rapidly. He suffered from tonic-clonic seizures, diminished consciousness, widespread mucosal bleeding and oliguria. Bilateral chest tubes were inserted for massive pleural effusion. The patient was treated with intravenous vancomycin, cefepim, gentamycin and oral rifampin. He received infusion of fresh frozen plasma, packed cells, valproic acid, diazepam and phenytoin.\nBased on his poor general condition, cardiac surgery was not performed and finally he expired from multi organ failure. Autopsy findings were consistent with clinical, laboratory and echocardiographic findings.