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 55-year-old man presented with rheumatic heart disease, severe mitral regurgitation, moderate pulmonary arterial hypertension, and good biventricular function. He was scheduled for mitral valve replacement (MVR). After applying standard monitors and preoxygenation, general anesthesia was induced with 2 mg of midazolam, 50 mg of propofol, 200 μg of fentanyl, 60 mg of lidocaine, and 8 mg of vecuronium. Anesthesia was maintained with oxygen: Air, 1% isoflurane, and intermittent doses of fentanyl. The trachea was intubated with an 8.5-mm single-lumen tracheal tube. A right femoral arterial catheter was placed for continuous blood pressure monitoring.\nMVR with 29 mm St. Jude mechanical prosthetic valve with posterior mitral leaflet preservation was performed through transseptal approach on conventional cardiopulmonary bypass (CPB) and cold blood cardioplegia. The patient was weaned off CPB with the optimal inotropic support of 5 μg/kg/min of dopamine and 5 μg/kg/min dobutamine. But, the pressures were on borderline around 80/38 mmHg, and right ventricle appears to be distending with poor myocardial contractions. So, we decided to put transesophageal echocardiography (TEE) probe to see for any abnormality. To our surprise, we saw a circular hypoechoic mass in the left atrial (LA) free wall encroaching onto the mitral valve []. This finding was discussed with the surgeon, who decided to re-explore the LA. LA atriotomy was reopened, the mitral valve appeared to be well seated, and there was no evidence of dissection. Only the LA free wall appeared to have subendocardial blood collection. There were no continuities between the cavity and the LA, left ventricle, posterior pericardial space. Marsupialization of the cavity is done and opened it to the LA cavity [].\nThe patient was then weaned from CPB for the 2nd time with inotropic support of 0.375 μg/kg/min of milrinone, 5 μg/kg/min of dopamine, 5 μg/kg/min dobutamine, and 0.05 μg/kg/min of nor epinephrine. The post-bypass TEE examination showed that LA dissection (LAd) wall appeared to be incised in the middle and drained out the blood.\nThe patient's postoperative course was complicated by intermittent periods of desaturation which required bi-level airway pressure ventilation with which he showed improvement in oxygenation. The patient was discharged from the hospital 15 days after surgery.