Anaesthetic management of patient with incidental left atrial myxoma posted for wound debridement in hand

Sir, Myxomas are rare benign tumors (0.5 per million population per year) that account for the 30–50% of all cardiac tumors and are most commonly located in the left atrium (>85%).[1] The clinical manifestations of cardiac myxomas may vary from having one of the three classic presentations (outflow obstruction, embolism, and constitutional symptoms) to having mild or no symptoms.[2] Here, we are presenting a case of patient with incidental left atrial myxoma planned for an emergency non cardiac surgery. In this case, we had planned to give regional anaesthesia in order to avoid complications of general anaesthesia and to maintain stable haemodynamics. Forty one-year-old male, manual laborer by occupation, came with complaints of burns in right hand followed by cracker burst, planned for wound debridement. Patient also had complaints of blurring of vision and vertigo; for which he got admitted under neurology, evaluated, and diagnosed to have acute posterior cerebral artery (PCA) infarct. As a part of evaluation, echocardiogram was done, which showed large left atrial myxoma measuring 14 x 40 mm arising from interatrial septum. [Figure 1]. All other laboratory investigations were within normal limits. On examination, he was well built male, weighing 73 kg with a height of 173 cm. The pulse rate was 76/min, regular in rhythm. Blood pressure was 132/86 mmHg. On auscultation, first and second heart sounds were heard and an additional “tumor plop” was heard. Patient was started on Inj. Enoxaparin 0.6 ml subcutaneous, once a day. After 3 days of neurology admission, As he improved symptomatically, was discharged and admitted under general surgery for wound debridement. Patient was advised to take oral antiplatelet drugs henceforth.Figure 1: Preoperative echocardiogram showing 14 x 40 mm sized left atrial myxoma arising from interatrial septumOn the day of surgery, on arriving to operation theatre, routine monitors were applied i.e., Electrocardiogram, pulse oximetry, and non invasive blood pressure. All the advanced cardiac life support drugs and instruments were kept ready and planned to give peripheral nerve block. Under ultrasound guidance, individual nerve blocks for radial, median and ulnar nerve were given with 0.5% bupivacaine 4 ml for each nerve [Figure 2]. Intraoperatively patient was pain free and hemodynamically stable. Postoperatively patient was shifted to post anaesthesia care unit and anaesthesia recovery was uneventful and on 2nd postoperative day patient was discharged home and advised to continue antiplatelet drugs and to follow up with cardiothoracic surgeon regarding left atrial myxoma.Figure 2: Ultrasound image showing needle targeting individual nerveCardiac myxomas usually develop in the atria. About 75 percent originate in the left atrium, and 15 to 20 percent in the right atrium. Myxomas may manifest with a variety of symptoms, though the classic triad includes embolism, intracardiac flow obstruction, and constitutional symptoms (Goodwin’s triad).[3] Hence, it is very essential to understand the physiological alterations caused by the myxoma, as we have to provide safe anaesthesia to these patients, especially, when they are presenting for a minor non cardiac surgery. Entrapment of the myxoma in the mitral valve during the course of anaesthesia can result in a cardiac arrest.[4] Most reported cases of myxomas are of patients who were posted for myxoma resection. The anaesthetic management of such cases for non-cardiac surgery is seldom reported. We preferred individual nerve blocks in order to avoid complications such as hypotension, intraoperative arrhythmia, cardiac arrest, particularly in such a minor procedure and also to start antiplatelet drugs as early as possible in the post operative period.[5] The potential and well-known advantage of regional anaesthesia over general anaesthesia should be an asset in cardiac patients if the surgery can be performed under regional block.[6] In our case, as the patient was on anti platelet drugs, we preferred individual nerve block blocks over plexus block in view of preventing any inadvertent vessel injury. Ultrasound guided nerve blocks are the most safe and effective way of providing perioperative analgesia, to avoid hemodynamic changes, especially in patients presenting with complications such as left atrial myxoma. Patients with left atrial myxoma may present with embolic events or may be asymptomatic. However, myxomas has to be excised once detected. This case report the challenges while anaesthetizing a patient with such complication, for a non-cardiac surgery. The patient has to be managed with a team of anaesthesiologist, cardiologist, and a surgeon in a multi-disciplinary approach for a better outcome. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Department of Anaesthesiology, CHRI; ESAOTE ultrasound machine. Conflicts of interest There are no conflicts of interest.