Giant incidental cardiac mass compatible with myxoma in a 92‐year‐old woman

To the Editor: Primary cardiac tumors of all types are rare, occurring in 0.0017% to 0.19% of autopsy.1 Myxomas are the most common benign neoplasms of the heart, representing the vast majority of all primary cardiac tumors.2, 3 Most patients with myxoma are 30 to 60 years of age, yet myxomas have also been discovered in octogenarians up to 89 years of age.4, 5 Cardiac myxomas classically present as one or more of the triad of constitutional, embolic, or obstructive symptoms. We describe an incidental diagnosis of a giant cardiac mass, compatible with myxoma, in the tenth decade of life. A 92-year-old, well-functioning, and cognitively normal woman was hospitalized after several episodes of weakness with retrosternal pain and dyspnea. She had a history of chronic atrial fibrillation, hypertension, and a cerebral stroke two years previously, with mild left hemiparesis. The patient did not have fever or other systemic inflammatory symptoms and no recent embolic event. Cardiac auscultation revealed arrhythmia with no murmur of mitral stenosis or “tumor plop.” Electrocardiogram confirmed a flutter-fibrillation rhythm with extensive anterior wall ST-T depression. The patient was not anemic. Erythrocyte sedimentation rate (ESR), C-reactive protein, complement, and serum globulin were all normal. In order to assess cardiac function, a two-dimensional echocardiogram was perforemd, showing left ventricular hypertrophy, calcified aortic and mitral valves, and a giant mobile pedunculated mass compatible with myxoma (5.5 cm × 1.8 cm), attached to the left aspect of the interatrial septum (Figure 1). During diastole, this mass protruded through the mitral orifice into the left ventricle (Figure 2). Doppler study showed no abnormal diastolic gradient over the mitral valve. A coronarography demonstrated three-vessel disease. Parasternal long axis view. Note: MYX = Myxoma; AML = Anterior Mitral Leaflet; PML = Posterior Mitral Leaflet; LV = Left Ventricle. Parasternal long axis view. Note: PROT MYX = Protruding Myxoma; AML = Anterior Mitral Leaflet; PML = Posterior Mitral Leaflet; LV = Left Ventricle. After discussing the various aspects of the treatment with the patient, a conservative approach was chosen. She was given warfarin and discharged. Eight months later the patient is medically stable and asymptomatic. Although we did not have histologic confirmation of this tumor, its benign course and echocardigraphic structure, which was a rounded, smooth, mobile pedunculated prolapsing type, enabled us to consider the almost certain possibility of a myxoma. The patient's complaints were attributed to ischemic heart disease. Indeed she had three-vessel coronary artery disease, while the echographic finding was completely incidental. Akihiro et al.6 reported that 16% of their patients with cardiac tumors were asymptomatic, diagnosed incidentally when echocardiography was performed as follow-up in patients with cardiovascular disease or as preoperative screening. In a report by Blondeau,2 only 2% of 444 patients with myxoma were asymptomatic. In both studies, the oldest patient was 86 years old. To our knowledge, the case presented is probably the first published incidental cardiac tumor in someone of this advanced age. Whereas myxoma is readily suspected in a young patient presenting with one or more symptoms of the classic triad, it can go unrecognized for long periods in the elderly. Moreover, important signs pointing towards the presence of an intra-atrial mass tend to be attributed to more prevalent disorders such as infections, atherosclerosis, and coronary heart disease.7 Increased life expectancy and the wide use of echocardiography should lead to some rise in cardiac tumor findings in geriatric patients.