Mobile Pedunculated Left Ventricular Masses in a Man with Recurrent Emboli
A 51-year-old man presented to the Neurologic Department because of right-sided weakness and recurrent left-sided paresthesias and bilateral visual disturbance for two weeks. He had a history of hypertension, diabetes mellitus, hyperlipidemia and smoking. He also had a history of myocardial infarction three years earlier.\nComputed tomography scan of the patient's brain demonstrated evidence of bioccipital ischemic infarct and multiple regions of lacunar infarction of basal ganglia and internal capsule. General hematological and biochemical tests were normal. To evaluate the source of emboli, Carotid Doppler measurements and transthoracic echocardiography was performed. Carotid Doppler measurements were normal. Transthoracic echocardiography showed mild left ventricular dilatation with moderate systolic dysfunction (ejection fraction 35-40%), akinesia of base of infeior segment andhypokinesia of lateral (base and mid) segment. There were two mobile masses in the left ventricle, one attached to the posterior wall of the left ventricle (2.5 × 1.8 cm) and another mass (2.8 × 2.2 cm) attached to the antrolateral wall of the left ventricle (mid part) which suggested cardiac tumor []. The patient was referred to our cardiology department for evaluation of cardiac masses. Transesophageal echocardiography was performed and confirmed TTE findings. Cardiac magnetic resonance imaging was not obtainable as a result of patient noncompliance. Due to our patient's regional wall motion abnormalities and history of myocardial infarction and diabetes, a coronary angiography was performed which showed severe three vessels disease. Our presumptive diagnosis was left ventricular myxoma. In view of these findings and the history of recurrent systemic embolism, the patient subsequently underwent open heart surgery for coronary artery bypass graft (CABG) and tumor resection. Trans-left atrial excision of the mass was performed through a median sternotomy with cardiopulmonary bypass. A reddish purple colored mass with an irregular surface (2.5 × 2 cm in diameter) was identified, that was attached to the posterior wall of the ventricle below the posterior mitral leaflet by a 2-3 mm tissue stalk about 1.5 cm under the mitral annulus. Another mass was not accessible trans-left atrium and mitral valve, thus a transverse aortotomy was performed. A reddish purple colored irregular surface mass (3 × 4 cm in diameter) that was attached to the antrolateral wall of the ventricle about 5 cm under the aortic annulus was excised. After resection of the masses CABG was performed. Postoperative recovery was uneventful. The histologic diagnosis revealed an organizing thrombus with no evidence of tumor cells [].\nThe patient was discharged with slight improvement of neurological deficit. Transthoracic echocardiogram showed no evidence of residual mass and ejection fraction had improved to 45%.