in clinical practice , paradoxical clinical results that require alternative strategies may be encountered . here
we present a case of a patient with results of cardiac catheterization that are incompatible with st segment elevation and elevated cardiac enzymes .
although technologically advanced diagnostic examinations are becoming increasingly available , noninvasive bedside ultrasound examination remains to be indispensable .
although cardiac myxomas are relatively uncommon compared with coronary and valve lesions in the elderly , they are easily diagnosed by basic echocardiography ; this diagnostic test may be the key to solving puzzling presentations and should a part of most cardiac workups .
stroke is a complication in 10% to 30% of cardiac myxoma patients as found in a case series spanning 20 years in belgium and a 11-year series conducted at the mayo clinic ; no cases of cardiac myxoma in either study had concurrent myocardial infarction .
forty cases of myxoma - related myocardial infarction were recorded in a systematic review of published data spanning 32 years .
this case report shares our experience with a rare case of cardiac myxoma with concurrent stroke and st - elevation myocardial infarction with normal coronary angiography .
signed consent from the patient was obtained , and approval was granted by the institutional review board of taipei tzuchi hospital for this case report . a 67-year - old unconscious woman presented to the emergency department of our hospital within 30 minutes of collapsing at an outdoor market
. she was afebrile with blood pressure of 100/80 mm hg , heart rate of 90 beats per minute , and respiratory rate of 26 breaths per minute on mask oxygen .
on physical examination , the patient displayed grimace in response to painful stimuli , pupils were equal and reactive to light , heart beats were regular without obvious murmurs , breath sounds were coarse without wheezing , abdomen was soft and nontender , urine was clear with adequate output into a foley bag , and legs were warm and nonedematous ; examination was otherwise unremarkable .
electrocardiogram showed significant st elevation in the inferior and lateral leads ( figure 1 ) .
chest x - ray showed lung congestion , minimal effusion in the pericardial and pleural spaces , and a narrow mediastinum . computed tomography of the brain showed no hemorrhage or detectable ischemia . although awaiting cardiac catheterization , she regained consciousness and was able to follow commands and move all extremities . however , severe orthopnea with respiratory distress developed , and she was endotracheally intubated .
we then performed echocardiography , which revealed an oscillating round mass measuring 3  3  cm inside the left atrium attached by a pedicle to the interatrial septum that was obstructing inflow through the mitral valve during diastole ( figure 2 ) .
although in the intensive care unit , the patient 's lung edema deteriorated rapidly , resulting in cardiogenic shock that required increased inotropic support and high - setting ventilator support .
echocardiograph of the oscillating left atrial myxoma ; surgical specimen of the completely resected atrial myxoma .
the myxoma was resected en bloc with its pedicle and adjacent interatrial septum ( figure 2 ) .
ataxia was noted during rehabilitation , and magnetic resonance imaging of the brain revealed left cerebellar infarction .
cardiac atrial myxoma is uncommon , with an estimated incidence of <  0.1% by autopsy series .
often initially asymptomatic , symptoms arise because of obstructive , embolic , or constitutional events .
a 20-year surgical cohort of cardiac myxoma cases in belgium estimated 65.6% of presenting symptoms to be obstructive and 15.6% to be embolic . as in our case
, emergent resection may be necessary if cardiogenic shock develops because of mitral valve obstruction .
echocardiography can readily reveal obstruction by a cardiac myxoma , usually of mitral valve inflow , allowing timely determination of severity and necessity for emergent surgical resection .
myxoma - related stroke is relatively more common than myxoma - related myocardial infarction for myxoma - related embolic events . in the aforementioned 20-year myxoma surgical series ,
brain ischemia was involved in 15.6% of cases , brain and peripheral artery embolic ischemia in 6.2% , and angina in 3.1% , whereas no cases involved myocardial infarction .
myxoma - related coronary artery embolism is rare and much less common than brain embolism .
estimated incidence of myocardial infarction in cardiac myxoma ranges from close to 0% to as high as 10% if coronary emboli is included .
a review of cardiac myxoma cases spanning 11 years conducted by the mayo clinic found that 12% of cases had image - evident stroke .
therefore , coexisting stroke and myocardial infarction , as in our case , are exceedingly unusual .
myocardial infarction with normal immediate angiography is rare for cardiac myxoma . in a systematic review of published data from 1970 to 2002 ,
patent coronary arteries were found only on latent angiography ( performed more than 2 weeks after the initial event ) , but not on immediate angiography .
negative latent angiography may be explained by recanalization performed days or weeks after the initial coronary events .
possible explanations may include rapid and spontaneous recanalization , a washout effect of embolic myxoma fragments or induced thrombi , or compromised hemodynamics because of mitral valve obstruction .
echocardiography , a noninvasive and portable examination , is often critical for properly identifying the etiology of cardiac conditions such as acute heart failure .
basic echocardiography , or focused cardiac ultrasound , is easily learned and often sufficient for detecting intracardiac masses or intrathoracic effusion .
our case demonstrates the importance of basic echocardiography for optimizing the management of cardiac cases , and supports the recommendation that basic echocardiography be readily available for most cardiac teams or acute care centers .
our atypical case of normal immediate coronary angiography in myxoma - related myocardial infarction with mitral valve obstruction and multisystem embolism ( heart and brain ) deserves attention because of the rarity of this combination of presentations .
the case stresses the value of basic echocardiography in the efficient and effective management of the patient and the importance of including it in most cardiac workups .
in addition , this experience is a reminder for clinicians to include cardiac myxoma in the differential diagnosis list and to manage it timely if found .
although cardiac myxoma may have unexpected presentations , it can be easily diagnosed by basic echocardiography and should not be missed .
once diagnosed , cardiac myxoma requires timely surgical en bloc resection to avoid deterioration resulting from worsening embolism or obstruction .
 abstractwe present a case of cardiac myxoma with atypical presentations of concurrent stroke and angiography - negative myocardial infarction . 
 the case emphasizes the importance of basic echocardiography and timely surgery in the management of cardiac myxoma.an elderly woman presented to the emergency department in an unconscious state . electrocardiogram and 
 elevated cardiac enzymes suggested acute myocardial infarction ; however , immediate coronary angiography proved patency . 
 basic echocardiography revealed an oscillating left atrial myxoma obstructing inflow through the mitral valve . after regaining consciousness while in the intensive care unit , the patient developed respiratory distress and shock , and emergent en bloc resection was performed . 
 ataxia was noted in her postoperative course and multiple small cerebellar infarcts were found on magnetic resonance imaging . after a 1-month period of rehabilitation , 
 the patient recovered well and continues to be followed as an outpatient.cardiac myxoma requires timely management and may be missed if not included in the differential diagnoses . 
 basic echocardiography , also called focused cardiac ultrasound , may aid in the diagnosing of perplexing cardiac cases . 