Atrial Myxoma.ppt
-
Upload
prince-jevon-yap -
Category
Documents
-
view
27 -
download
6
Transcript of Atrial Myxoma.ppt
-
A lady with acute SOBSammi Pe
-
Case Presentation54/FCat IIBP 129/69mmHg P 128Temp 36.9 SpO2 78% ( 100% O2)Triage : SOB since afternoon, cough with sputum, mild chest discomfort
-
What will you do ?What further history need?
-
What further Hx Good Past HealthDomestic helperSOB since ~2 hrs agoMild cough with yellowish sputum xdays become blood stained on AEDNo fever Chest discomfort today ( tightness)Palpitation +ve
-
More hx from employerMild exertional SOB x several daysNeed resting after her workNo fever all alongNo Travel hxWork in HK x ~17yrsNo GI upset/ abd painNot on regular medication Non-smoker, non-drinker
-
P/EAlert GCS 15/15BP 139/78 P 120RR 48Sit up for breathingSpO2 80% on 100% O2Recheck Temp 37.2Hstix 13.2
-
P/E Chest: AE fair with bilateral basal crep, occ wheezeAbd softHS dual, no murmurNo ankle edema
-
What will you do next ?
-
ABC100% O2 maskHB setBlood x CBC, L/RFT, Trop I , ClottingECG i stat ( arterial) CXR
-
ECG x 2
-
i stat (arterial, on 100%O2)pH 7.398pCO2 5.39 kPapO2 5.8 kPaBE 0HCO3 24.9 mmol/LSO2 79%Na 141 K 3.5 i Ca 1.21 Hb 14.6
-
Our PatientProblem:Sudden onset SOBDesaturation even on 100% O2Type I Resp Failure
What is yr DDx?
-
Type I Resp FailureTypically due to V/Q mismatch PaO2 low (< 60mmHg(8.0kPa)) PaCO2 normal or low PA-aO2 increasedParenchymal disease (V/Q mismatch) Diseases of vasculature and shunts: right-to-left shunt, pulmonary embolism interstitial lung diseases: ARDS, pneumonia, emphysema.
-
Patient was still in distress even on 100% O2What will you do then?
-
Patient was put on CPAPLasix 40mg iv
BP 110/70 Clinically improved
CXR film A/V.
-
CXRWhat is yrDiagnosis?
-
APO . ? Other drug(s) to be considered? Underlying cause
CCU was consulted
-
MedicationsNitratesVasodilationReduced preload and afterloadImproved CORapid effectNot prescribed likely due to BP on low sideDiureticsReduced plasma volume / preloadPulmonary vasodilatation
ACEIReduced afterloadImproved CO
-
Underlying CausesACSHTAortic/mitral valve diseaseArrhythmias
VSD CardiomyopathyAcute myocarditisPericardial diseaseAtrial myxoma
Echo was performed
-
Our case
What is show in the Echocardiogram?
-
CCU inputECHO: LA mass ~4cmLikely atrial myxomaTrivial MR/ARNormal LV size and EF
-
Our PatientAPO secondary to large atrial myxoma
Transfer to CCU then CTSU for further Mx.
-
ProgressEmergency excision of atrial myxoma 6x5cm encapsulated LA tumour attached to inter-atrial septum.Causing obstruction & pul edemaBi-atrial exploration + excision of tumourExtubated on D1Post-op echo: EF 70% no PE
-
Day 0 Day 1 Day 2
-
Day 3 Day 4 Day 20Patient was discharge on D8 and SOPD FUOn Day 20Good Recovery, Class I II , ET 3-4 FOS
-
Atrial Myxoma
-
Background Most common 1 Heart tumour (40-50%)90% solitarty and pedunculatedMultiple tumours occur in 50% of familial case10% familial ( autosomal dominant)75-85% occur in LA ~25% RAAttach to fossa ovalisSymptomatic ~ 70g 140g
-
Myxoma- polypoid, round, oval in shapeSmooth / lobulated surfaceWhite/ yellow/ brownProduce numberus growth factors and cytokines e.g. interleukin-6
-
Histologylipidic cells embedded in a vascular myxoid stroma
In a series of 37 cases, 74% of tumors showed immunohistochemical expression of interleukin-6 while 17% had abnormal DNA content
-
EpidemiologyUS ~ 75 case / million autopsies75% sporadic Female Mean age 56 15% present as sudden death tumour embolism, HF, mechanical obstruction
-
History Asymptomatic (20%) symptomatic sudden death (15%)
Mechanical interference with cardiac fx embolization
LHF RHF systematic (L) Pulmonary (R)Exertional SOB fatigue infarct / haemorrhage PEOrthopnea peripheral edema of viscera Pul infarctionPND ascites e.g. CVA Pul HTPul edema visual lossPostural dizziness
Constitutional symptoms : fever, Wt loss, arthralgias, Raynaud ~ 50% of patient due to interleukin-6 overporduction
-
Physical JVPLoud S1 ( delay mitral valve closure)Early diastolic sound (Tumor plop) tumor hit against the endocardial wall Diastolic atrial rumble ( obstruction in MV)MR/ TR ( valvar damage/ prolapse)
-
DDXMitral RegurgitationMitral StenosisPul EmbolismPul HT , primary Tricuspid RegurgitationTricuspid Stenosis
-
IxLab: ESR, CRP, CBC, serum interleukin-6CXRECHO need to differentiate thrombus from myxoma Thrombus ( in posterior portion, in layers)Myxoma ( presence of stalk and mobility) MRI (point of attachment )CT scan
-
Treatment Medical treatment for CHF and arrhythmiaSurgical excision is the definitive txSafe and curativeRecurrence is possible if incomplete excision
-
Thank you
*ST HR 118 P pulmonalePoor R wave progression*