PMC4879800_01
(a) Modified apical 4 chamber view TTE showing a 2.4 cm x 2.4 cm pedunculated myxoma in the right atrium (RA) attached to RA free wall extending to interatrial septum, (b) Modified apical 4 chamber view TTE showing 1.1 cm x 1.1 cm pedunculated myxoma attached to the septal leaflet of the tricuspid valve, (c) CW Doppler across the tricuspid valve showing severe high-pressure TR with 60 mmHg gradient, (d) TTE basal short axis view showing dilated RVOT, pulmonary artery and heterogenous pedunculated right atrium mass with calcium specks attached to RA free wall
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F1
Transthoracic echocardiogram showed a large pedunculated mobile mass in RA with heterogenous echotexture attached to RA free wall and another mass attached to interatrial septum near fossa ovalis [Figure 1a]. Another mass was seen in RV measuring 11 mm x 11 mm just beneath the septal leaflet of tricuspid valve [Figure 1b]. RA mass was prolapsing into RV producing severe eccentric TR jet with a gradient of 60 mmHg [Figure 1c, supplementary movie 1]. RV outflow tract and PA was dilated [Figure 1d].
(a) High-resolution computed tomography of the thorax showing embolic fragment in the lateral aspect of right pulmonary artery (PA) and medial aspect of left PA, (b) High-resolution computed tomography thorax showing pulmonary infarct in left lung field
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F2
HRCT thorax revealed embolization to the lateral aspect of right PA and along the medial aspect of left PA causing subtotal obstruction with pulmonary infarct in left lung [Figure 2a and b].
(a) Intra-operative findings showing 3 right atrial myxomas one of which the largest one attached to right atrial free wall, (b) Gross morphology of excised myxoma: Pedunculated lobulated mass held by forcep and degenerating myxomatous mass with hemorrhage seen on extreme left side of picture, (c) Photomicrograph (H and E, x100) loose myxomatoid stroma with stellate and spindle cells (from right atrium mass), (d) Photomicrograph (H and E, x45) myxoid stroma with scanty stellate cells and spindle cells amidst degenerating cells and hemorrhage (from right ventricle mass)
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F3
Another solitary mass was excised from the RV originating beneath the septal leaflet of tricuspid valve [Figure 3a and b]. Microscopy revealed hypocellular tumor tissue with myxoid background, isolated spindle and stellate cells with no abnormal mitosis or pleomorphism [Figure 3c and d].