DISCUSSION
Cardiac tumours are amongst the rare diseases of heart with incidence of 0.02 %. Metastatic tumours are more common to heart as compared to primary tumours. Median age of presentation is 50 years (1). Atrial myxoma constitutes about more than 50% of all benign cardiac neoplasms. 75% of all Atrial Myxoma arises from left atrium, with majority originating at the edge of fossa ovalis, while 15-20% arises from right atrium; commonly at the edge of fossa ovalis. Bilateral myxoma represents extension from one atrium to another via foramen ovale. 3-4% of myxoma arises from ventricle with biventricular extension rarely seen. Vast majority are sporadic with male: female ratio 1:3. 5-10% are familial with slight male preponderance and are multicentric and more likely to recur.(2)
Clinical manifestations are due to location of the myxoma, propensity of embolization and nonspecific constitutional symptoms elaboration of cytokines by the tumour. Patient may present with symptoms of left sided or right sided cardiac failure, depending upon site of mass, point of obstruction caused by the mass. Valvular masses can cause insufficiency or relative stenosis of the mass. Left sided mass can embolise to systemic circulation causing stroke, acute limb ischemia.(3) Echocardiography is initial modality of choice, with advantage of temporal as well as spatial resolution the evaluating the motion of pedunculated tumour in cardiac chamber and its effect on the normal contraction , valvular function and blood flow during cardiac cycle(6). ECG gated CT and MRI can provide additional information in terms of tumour diagnosis, extent and involvement. Treatment is surgical excision of myxoma with cuff of normal endocardium to decrease chances of recurrence and it is usually curative. Resulting defect is closed primarily if possible or with autologous or bovine pericardium. Prognosis is excellent with expected survival equivalent to general population. Overall rate of embolization with cardiac tumour is around 25 %, with tumours in let atrium and aortic valve with maximum embolic potential (4) this is the reason the cases of LA Myxoma should be operated as soon as possible.
Resection of LA myxoma requires CPB support. Although there are no set guidelines for commencing cardiopulmonary bypass in cases of Myxoma, The society of Thoracic Surgeons Clinical Practice Guidelines published in 2011; recommend delaying surgery for Infective Endocarditis complicated by intra cranial bleed by up to 4 weeks from onset of cerebrovascular complications, due to the risk of extension of haemorrhage potentially causing lifelong morbidity or life threatening consequences from existing site of intracranial bleed.(7) Considering the risks of the extension of intracranial bleed, the surgery was delayed by 4 weeks in our patient.