Cardiac myxoma and beyond: A case of benign tumor

Karpagam1*, Ponraj.K2

1Nursing Supervisor, Kauvery Hospital, Tirunelveli, Tamil Nadu

2Senior Staff Nurse, Kauvery Hospital, Tirunelveli, Tamil Nadu

*Correspondence

Case presentation

A 42 year old Female with a following Chief Complaint

  • Acute dyspnea (breathlessness) since this morning.
  • Palpitation / chest discomfort of intermittent nature for 1 month.
  • Generalized body pain.

Past medical history

  • Polymyalgia – Treated with hydroxychloroquine and analgesics.
  • No known medical history of type 2 diabetes mellitus (T2DM), hypertension (SHTN), coronary artery disease (CAD), cerebrovascular accident (CVA), bronchial asthma (BA), or thyroid disease.

Family history: Has no family history

Physical examination

General: Patient is conscious and oriented.

Vitals

Pulse rate (PR)92 /min.
Blood pressure (BP)110/70 mmHg.
Respiratory rate (RR)38 /min.
Oxygen saturation (SpO₂)89 % on room air (RA).
Cardiovascular System (CVS)S1 S2 present (+).
Respiratory System (RS)Bilateral air entry equal (BAE) (+).
Per Abdomen (P/A)Soft, bowel sounds present (BS +).
Central Nervous System (CNS)No focal neurological deficit (NFND)

Clinical findings

Auscultation: A characteristic “Tumor Plop” heard during early diastole (the sound of the tumour hitting the mitral valve).

Risk: High risk of “Mitral Valve Obstruction” (sudden cardiac collapse) and systemic embolism (Stroke).

Diagnostic studies

The echocardiogram report dated 29.01.2026 indicates the following findings:

  • CAD involving LAD territory: Coronary artery disease affecting the Left Anterior Descending artery territory.
  • Normal LV systolic function: The left ventricle’s pumping (systolic) function is normal.
  • Stage I diastolic dysfunction: Mild impairment of the heart’s relaxation phase (diastole).
  • Large LA myxoma: A large myxoma (benign cardiac tumor) in the left atrium.
  • MR (Mild) & TR (Mild): Mild mitral regurgitation and mild tricuspid regurgitation.

Lab Results Comparison Table

InvestigationPatient ValueNormal RangeClinical Significance
Haemoglobin10g/dl12–16 g/dLAnemia due to IL-6
ESR40 mm/hr0–20 mm/hrHigh inflammatory response
Potassium5.5 mmol/L3.5–5.0 mmol/LSafe for bypass/cardioplegia
INR1.40.8–1.2Safe for surgical incision
CRP12mg/L<5 mg/LSystemic inflammation
Troponin I 0.21 ng/mL < 0.04 ng/mLindicates heart muscle stress or damage
Brain Natriuretic Peptide6687 pg/ml<100 pg/mL extremely high and indicates severe, acute heart strain,

Diagnosis

Large left atrial (LA) myxoma with acute pulmonary edema/rheumatoid arthritis

Discussion

Most myxoma patients present with one of three “Classic” complaints:

  • Dyspnea (Shortness of Breath): Often worse when lying on a specific side (usually the left), as gravity moves the tumor to block the Mitral Valve.
  • Palpitation / chest discomfort of intermittent nature for 1 month.
  • Neurological Deficit: complaints of generalized A sudden “mini-stroke” (? TIA) for 2 months ago

Atrial Myxoma

In humans, a myxoma is a non-cancerous (benign) tumor of the heart. It is the most common type of primary heart tumor in adults.

Location: About 75% occur in the left atrium (the upper left chamber of the heart), usually attached to the wall separating the chambers (the septum).

Image Source: St Vincent Hospital Heart Health

Treatment: Immediate surgical removal is the standard treatment and is usually curative.

Pre-operative Nursing Goals

Embolic Protection (The “Physical” Safety)

Since a Myxoma is often “friable” (crumbles easily), any sudden movement or increase in heart rate could break off a piece, sending it to the brain.

Gentle Handling & Positioning

  • The “Log-Roll” approach: When transferring the patient from the ward bed to the theatre trolley, use a slide board and at least 4 staff members to ensure a smooth, horizontal transfer without jarring movements.
  • Avoid “Thumping”: When positioning for the Sternotomy (placing the bolster behind the shoulders), do it slowly. Sudden chest impact can dislodge tumor fragments.

Hemodynamic Stability

  • Keep them “Cool”: Anxiety increases heart rate and contractility (how hard the heart beats). A pounding heart increases the risk of the tumor “plopping” through the mitral valve and breaking.
  • Pre-medication Coordination: Work with the Anaesthesiologist to ensure the patient is adequately sedated before moving them onto the operating table.

Vigilant Monitoring

The “Neuro-Baseline”: Perform a quick “Grip and Wiggle” check (squeeze hands/move toes) right before induction. If they wake up with a deficit, you need to know exactly what their baseline was.

Nursing Documentation Checklist (Pre-Op)

Ensure these are addressed in your presentation as “Nursing Actions”:

  • Consent Verification: Confirm consent specifically mentions “Excision of Atrial Myxoma +/- Septal Repair.”
  • Skin Prep: Gentle Chlorhexidine/Betadine scrub of the chest. Caution: Do not apply heavy pressure over the sternum during prep.
  • Blood Products: Ensure 4-6 units of Cross-matched Packed Red Cells are in the theatre fridge (standard for bypass cases, but vital here if the excision becomes complex).

Pre-op Goals: Embolic protection and patient reassurance

Median Sternotomy & Exposure

  • The Action: The surgeon opens the chest and pericardium.
  • Nursing Alert: “The Gentle Touch.” Remind the team to avoid heavy manual manipulation of the heart before bypass.
  • Scrub Role: Have the sternal saw ready and checked. Ensure bone wax and cautery are on standby to maintain a dry field for visualization.

Perioperative Nursing Highlights (The “Brief” Summary)

“The Three Safety Pillars for this Case”

  • Embolic Protection: Gentle positioning and “No-Touch” technique until cross-clamped.
  • Instrumentation: Ensure Atrial Retractors (for visibility) and Patch Materials (for repair) are on the field before the bypass begins.
  • Specimen Care: Correct labeling and immediate photography (if per policy) to confirm complete removal.

The surgical notes describe a procedure of left atrial (LA) myxoma excision performed under general anaesthesia (GA) with cardiopulmonary bypass (CPB). Key points from the document are:

Procedure

Myxoma excision via sternotomy, SVC and IVC cannulation, and pericardium opening.

  • CAG performed on 31.01.2026 with patient consent.
  • Planned for repeat LA myxoma excision on 04.02.2026 after clinical improvement and informed consent.

Steps

  • Aorta-bicaval CPB established.
  • Heart arrested with delnido cardioplegia.
  • Myxoma excised along with pedicle; IAS (interatrial septum) opened for access and then closed.
  • Right atrium (RA) opened and closed after deairing.

Findings

  • Right ventricle (RV) and pulmonary artery (PA) dilated.
  • Myxoma had a jelly‑like consistency; some pieces broke and were suctioned out.
  • Thorough saline wash given; hemostasis secured with a drain tube left in situ.

Surgical Outcome

  • Surgical Success: The tumor was excised with clear margins (no residual stalk).
  • Hemodynamic Stability: The patient was successfully weaned from Cardiopulmonary Bypass (CPB) on minimal inotropic support.
  • TEE Confirmation: Post-procedure Echo done.

Post-operative period

  • The patient was shifted to CT ICU on a ventilator (SIMV + PS mode) after surgery and slowly weaned off to CPAP/PS mode.
  • The patient was treated with IV fluids, IV antibiotics, FPI’s, Inj. Citicoline Noradrenaline, Inj. NTG (Nitroglycerin), and Torsemide.

Post-Operative Course

  • 02.2026: Extubation done; physiotherapy and spirometry exercise initiated.
  • 02.2026: Patient planned for IV antibiotics changed to oral drugs; 1 unit PRBC transfusion done.
  • 02.2026: DT removed; RFT normal.
  • 02.2026: X‑ray chest showed low Hb (7.1); patient shifted to room. General surgeon opinion obtained for fissure in Anus; advised Tab. Metro for constipation and treated symptomatically.
  • 02.2026: Repeat Echo – S/P LA myxoma MR (mild); normal LV functions and contraction.

Conclusion

Patient is clinically improved and discharged with symptomatic treatment. The patient has a good prognosis post-surgical excision of LA myxoma with mild MR. Close follow-up is advised to monitor for recurrence and manage symptoms.

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