New Onset Heart Failure in a Geriatric Patient

To the Editor: A 76-year-old man was admitted to the hospital as a result of three days of progressive shortness of breath. He had no previous history of hypertension, coronary artery disease, heart failure, stroke, or transient ischemic attacks. He had had reasonable exercise tolerance until 3 days before admission. Clinically, he was in pulmonary edema. EKG showed sinus tachycardia 120/min. Chest X-Ray showed pulmonary venous congestion and interstitial edema. Urgent two-dimensional echocardiography showed a large atrial mass measuring 3 × 7 cm that moved freely with the cardiac cycle, going in and out of the mitral valve orifice. The left ventricle appeared to be well preserved, with normal ejection fraction. The atrial myxoma was excised, and the patient recovered after the operation. Myxoma is the most frequently found tumor of the heart, comprising 30 to 50% of the total in most pathological series. The mean age of the patient with sporadic myxoma is 56 years, and 70% are female. Approximately 86% of myxomas occur in the left atrium, and more than 90% are solitary. In the left atrium, the usual site of attachment is in the area of the fossa ovalis. Approximately 7% of all myxomas are familial, and they appear to be transmitted in an autosomal dominant way. In this group, two myxoma syndromes have been recognized as NAME (nevi, atrial myxoma, myxoid neurofibroma, ephelides) and LAMB (lentigines, atrial myxoma, and blue navi). These groups of patients are younger (mean age 20s).1,2 Clinical presentations of cardiac myxoma can be signs and symptoms of mitral valve disease (43.8%), embolic phenomena (27.6%), incidental findings (12.3%), tricuspid valve disease (4.6%), sudden unexpected death (3.8%), pericarditis (3.0%), myocardial infarction (2.3%), pulmonary valve disease (1.5%), and fever of undetermined origin (1.5%).3 Even in the absence of systemic hypertension and coronary artery disease, the symptoms of congestive heart failure can easily be attributed to arteriosclerotic heart disease, especially in older patients with atrial myxoma, and diagnosis of atrial myxoma can be missed.4 Awareness of cardiac myxoma is the key to diagnosis in older patients presenting with heart failure, fatigue, weight loss, and syncope attacks of recent onset. Syncope can sometimes be associated with specific postures such as sitting or leaning forward because of movement of a pedunculated migratory tumor into the left ventricular inflow tract. Cardiac murmurs are variable in myxoma and are not distinguished readily from those of valvular disease. The tumor may produce a distinctive early diastolic sound, termed a tumor plop by some, which occurs from 0.08 to 0.15 seconds after the second heart sound. The sound is produced as the tumor mass suddenly ends its excursion into the left ventricle. The first heart sound has also been described as being loud, widely split, or prolonged. Murmurs typical of mitral stenosis and/or regurgitation are common in patients with atrial myxoma. Two dimensional echocardiography (Figure 1) is the technique of choice in identifying intracardiac masses. However, even combined two-dimensional and M-mode echocardiography have limitations in the detection of atrial myxoma, and caution is suggested when interpreting a negative study in the face of suggestive clinical features. It is possible that atrial myxomas in the geriatric population have been underdiagnosed. Therefore, thorough history taking and clinical examination, careful auscultation, and evaluation of heart murmurs in the geriatric patients may be the most rewarding. A large left atrial myxoma obstructing the inflow tract of the left ventricle.