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Case Presentation
54/F Cat II BP 129/69mmHg P 128 Temp 36.9 SpO2 78% ( 100% O2) Triage : SOB since afternoon, cough with sputum, mild chest discomfort
What further Hx
Good Past Health Domestic helper SOB since ~2 hrs ago Mild cough with yellowish sputum xdays become blood stained on AED No fever Chest discomfort today ( tightness) Palpitation +ve
P/E
Alert GCS 15/15 BP 139/78 P 120 RR 48 Sit up for breathing SpO2 80% on 100% O2 Recheck Temp 37.2 Hstix 13.2
P/E
Chest: AE fair with bilateral basal crep, occ wheeze Abd soft HS dual, no murmur No ankle edema
ABC 100% O2 mask HB set Blood x CBC, L/RFT, Trop I , Clotting ECG i stat ( arterial) CXR
ECG x 2
Hb 14.6
Our Patient
Problem: Sudden onset SOB Desaturation even on 100% O2 Type I Resp Failure What is yr DDx?
Parenchymal disease (V/Q mismatch) Diseases of vasculature and shunts: right-to-left shunt, pulmonary embolism interstitial lung diseases: ARDS, pneumonia, emphysema.
CXR
What is yr Diagnosis?
APO .
Medications
Nitrates
Vasodilation Reduced preload and afterload Improved CO Rapid effect Not prescribed likely due to BP on low side
Diuretics
Reduced plasma volume / preload Pulmonary vasodilatation
ACEI
Reduced afterload Improved CO
Underlying Causes
ACS HT Aortic/mitral valve disease Arrhythmias VSD Cardiomyopathy Acute myocarditis Pericardial disease Atrial myxoma
Our case
CCU input
ECHO: LA mass ~4cm Likely atrial myxoma Trivial MR/AR Normal LV size and EF
Our Patient
APO secondary to large atrial myxoma
Transfer to CCU then CTSU for further Mx.
Progress
Emergency excision of atrial myxoma
6x5cm encapsulated LA tumour attached to inter-atrial septum. Causing obstruction & pul edema Bi-atrial exploration + excision of tumour
Day 0
Day 2
Day 1
Day 3
Day 4
Day 20
Patient was discharge on D8 and SOPD FU On Day 20 Good Recovery, Class I II , ET 3-4 FOS
Atrial Myxoma
Background
Most common 1 Heart tumour (40-50%) 90% solitarty and pedunculated
Multiple tumours occur in 50% of familial case
10% familial ( autosomal dominant) 75-85% occur in LA ~25% RA Attach to fossa ovalis Symptomatic ~ 70g 140g
Myxoma polypoid, round, oval in shape Smooth / lobulated surface White/ yellow/ brown Produce numberus growth factors and cytokines e.g. interleukin-6
Histology
lipidic 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
Epidemiology
US ~ 75 case / million autopsies 75% sporadic Female Mean age 56 15% present as sudden death
tumour embolism, HF, mechanical obstruction
History
Asymptomatic (20%) symptomatic sudden death (15%)
embolization
Pulmonary (R)
PE Pul infarction Pul HT
RHF
fatigue peripheral edema ascites
systematic (L)
infarct / haemorrhage of viscera e.g. CVA visual loss
Physical
JVP
Loud S1
( delay mitral valve closure)
tumor hit
DDX
Mitral Regurgitation Mitral Stenosis Pul Embolism Pul HT , primary Tricuspid Regurgitation Tricuspid Stenosis
Ix
Lab: ESR, CRP, CBC, serum interleukin-6 CXR ECHO
need to differentiate thrombus from myxoma
Thrombus ( in posterior portion, in layers) Myxoma ( presence of stalk and mobility)
Treatment
Medical treatment for CHF and arrhythmia Surgical excision is the definitive tx Safe and curative Recurrence is possible if incomplete excision
Thank you