A Rare Cause of Dyspnea: Giant Atrial Myxoma in a Pregnant Patient

A 37 years old woman, without previous cardiovascular history, was admitted in our center referring one year of progressive exertional dyspnea. The ambulatory studies (Electrocardiogram and blood tests) were non-diagnostic and she presented remission of symptomatology during pregnancy.

During postpartum, progressive dyspnea reappeared. At physical examination a systolic murmur, significant ascites and bilateral pretibial edema were notable.

The electrocardiogram showed sinus tachycardia with left atrial abnormality and complete right bundle branch block.

An echocardiogram demonstrated a large left atrial mass (10 × 3.8 cm) with protrusion until halfway of the left ventricle occupying most of the mitral valve orifice and producing severe mitral stenosis with a mean mitral gradient of 11 mmHg (Fig. A, B and C). A right ventriculoatrial gradient of 60 mmHg was detected. The inferior vena cava was dilated (26 mm), with no inspiratory collapse. A systolic PAP of 75 mmHg was estimated corresponding to severe pulmonary hypertension. (Fig. D)

Figure 1

The right ventricle was moderately dilated presenting hypokinesia of the free wall with paradoxical systolic septal motion due to pressure overload

Surgical resection of the atrial mass by biatrial approach was performed and the diagnosis of atrial myxoma was confirmed by histopathology. (Panel E)

After surgery, the symptomatology disappeared completely. Post-surgical echocardiogram demonstrated significant decrease of pulmonary hypertension (systolic PAP estimated of 40 mmHg) and improvement of the right ventricular function.

Dyspnea during pregnancy and postpartum is a relatively common symptom. The differential diagnosis is broad and includes etiologies as pulmonary embolism, pneumonia and severe preeclampsia. Primary Cardiac tumors as atrial myxomas are an exceptional cause and are usually not considered as an initial option. Despite the increased frequency in women, there are few cases reported in pregnancy and in the reported cases predominate dyspnea with pulmonary edema and acute embolic events with premature birth.