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Year : 2020  |  Volume : 10  |  Issue : 4  |  Page : 289-291  

“YoYo” ball in heart: Uncommon cause of dyspnea in an elderly female

Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission26-Jun-2019
Date of Decision25-May-2020
Date of Acceptance08-Jul-2020
Date of Web Publication04-Oct-2020

Correspondence Address:
Akshyaya Pradhan
Department of Cardiology, King Georgefs Medical University, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijabmr.IJABMR_225_19

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Atrial myxomas are the most common primary tumors of the heart. Their presentation will vary depending on their anatomical site and many times remain asymptomatic. Local obstruction to atrial outflow can present with dyspnea, orthopnea, syncope, and rarely sudden death. A differential diagnosis of tumor in the left atrium includes thrombus. Echocardiography usually suffices in making a diagnosis, but in difficult cases, cardiac computed tomography and magnetic resonance imaging may be needed. We report a case of left atrial myxoma in an elderly female which was asymptomatic and presented with rapid deterioration of symptoms.

Keywords: Ball valve, cardiac tumor, myxoma, octogenarian

How to cite this article:
Pradhan A, Gupta V, Vishwakarma P, Sethi R. “YoYo” ball in heart: Uncommon cause of dyspnea in an elderly female. Int J App Basic Med Res 2020;10:289-91

How to cite this URL:
Pradhan A, Gupta V, Vishwakarma P, Sethi R. “YoYo” ball in heart: Uncommon cause of dyspnea in an elderly female. Int J App Basic Med Res [serial online] 2020 [cited 2021 Dec 3];10:289-91. Available from: https://www.ijabmr.org/text.asp?2020/10/4/289/297253

   Introduction Top

Atrial myxomas are the most common primary tumor of the heart and have a predilection for occurrence in the left atrium. Depending on their anatomic site, size, and ability to move, their presentations may vary from an asymptomatic patient to those with nonspecific constitutional manifestation such as fever and weight loss, leading to a delay in diagnosis. Common presenting symptoms due to intracardiac obstruction of flow include progressive dyspnea, orthopnea, fatigue, presyncope, syncope, and rarely sudden death. We report a case of left atrial mass producing “ball valve” or “Yo-Yo Ball” effect on the mitral valve in a septuagenarian female, which ultimately culminated in the death of the patient.

   Case Report Top

A 76-year-old female presented to the emergency department with progressive palpitations and dyspnea for the last 7 days. She denied any chest pain or syncope. Interestingly, she complained dyspnea only on lying down but felt relief on sitting position. There was no prior history of effort angina or dyspnea. She lacked any conventional cardiovascular risk factors apart from age. Although her blood pressure was stable, there were tachycardia and tachypnea on examination. Her respiratory examination was normal, but cardiac auscultation revealed a third heart sound which was more prominent in the upright position. The 12-lead echocardiogram [Figure 1] and routine Chest X-ray [Figure 2] were normal. Cardiac enzymes (high-sensitive cardiac troponin T) were negative, while the NT pro-BNP value was mildly positive (340 pg/ml). A provisional diagnosis of pulmonary thromboembolism was made. Two-dimensional echocardiography however made startling revelations. A well-defined, homogenous, globular mass of 3 cm × 3 cm was seen in the left atrium and was found to obstruct the mitral valve intermittently (”ball valve phenomenon.”) The mass was pedunculated and attached to the free wall of the left atrium [Figure 3] and Video 1]. Surgical opinion was sought, and immediate removal was advised by the cardiothoracic team. However, the patient and her family refused surgical procedure due to advanced age and sociocultural beliefs. She was given supportive treatment in the form of intermittent diuretics, supplemental oxygen, and sedation. Two days later, she developed progressive hypotension and intravenous vasopressors were administered. However, she soon developed respiratory arrest and collapsed.
Figure 1: A 12-lead electrocardiogram showing the absence of any significant abnormality

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Figure 2: Chest X-ray posteroanterior view demonstrating the absence of gross cardiac and pulmonary pathology

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Figure 3: Two-dimensional transthoracic echocardiogram showing a rounded, mobile as well as circumscribed mass in the left atrium giving the appearance of a “canon ball.” (upper panels). The mass is obstructing the mitral outflow tract in diastole like a “ball valve” (lower panels

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   Discussion Top

Atrial myxomas are the most common benign primary tumors of the heart. Other common cardiac masses in heart cavities are thrombus, myxoma, lipoma, and other tumors. Cardiac myxoma is usually found as a mobile mass attached to the endocardium of the heart by a stalk.[1],[2] They generally present in the fifth decade of life (30–60 years) but are seen in the second decade when occurring as familial clusters.

The commonly seen symptoms and signs of myxoma are dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, pulmonary edema, hemoptysis, and fatigue.[1] These symptoms sometimes appear or worsen in certain body positions, due to the motion of the tumor within the heart. When a left atrial mass is of critical size, posture and changes in intrathoracic pressure may cause obstruction of the mitral valve orifice producing signs and symptoms, and this was seen in our patient.[1] Pinede et al. found obstructive symptoms of myxoma in 67% of patients.[3] In around 30% of patients, constitutional symptoms (e.g., fever and weight loss) are seen. On physical examination, a characteristic “tumor plop” may be heard early in diastole. There are several mechanisms by which cardiac tumors may cause symptoms.[1],[4],[5] The obstructive circulation through the heart or heart valves produces symptoms of heart failure. Atrial myxoma may interfere with heart valves, causing regurgitation. Myxoma may invade the myocardium directly, resulting in myocardial dysfunction, arrhythmias, or pericardial effusion. Fragments of left atrial tumors may cause embolization into the systemic circulation leading to various systemic manifestations, the most serious of which is stroke. Myxoma can be diagnosed easily using echocardiography because of its characteristic appearance.[5] However, when the characteristics are not well defined, diagnostic errors may pose problem. Ill-defined attachment site of tumor, very small tumor size, and smooth contours of the mass are some difficult issues to be encountered during echocardiographic imaging. Cardiac thrombi are usually seen in the body of the left atrium or left atrial appendages.[3] Presence of organic heart disease is common in patients with atrial thrombus. A left atrial mass is mostly proven to be a thrombus if it is associated with the presence of atrial fibrillation, enlarged atrial chamber, prosthetic mitral valve, diseased mitral valve, low cardiac output state, and spontaneous atrial echo contrast. Myxomas are usually larger than thrombi. Transesophageal echocardiography (TEE) is a useful diagnostic tool to evaluate intracardiac mass involving the left atrium.[5] Left atrial myxomas and thrombi can be further evaluated using cardiac computed tomography (CT) scan or cardiac magnetic resonance imaging (MRI). These imaging techniques give accurate answers regarding the size, shape, origin, mobility, and prolapse of the mass. Positron emission tomography (PET) scan is also useful in identifying cardiac involvement in patients with metastatic tumors or atrial myxoma. Biopsy and histopathological examination is the gold standard to confirm the diagnosis of the mass. When the thrombus is a possibility and a myxoma could not be ruled out, a trial of anticoagulation may be given. Surgical removal of a mobile left atrial mass is the treatment of choice and should be performed before the occurrence of embolic complications. Hence, transthoracic echocardiography is a valuable tool, in the diagnosis of large atrial mass, available bed side. TEE, CT, MRI, PET, and biopsy are helpful in further confirming the diagnosis.[4],[5],[6]

In our patient, the intracardiac mass seen was mobile, was smooth surfaced, and its echogenicity was more consistent with that of myxoma. Other intracardiac masses such as lipoma or other tumors are rare. There was no evidence of any organic cardiac disease. The patient was in normal sinus rhythm. There was no history or event related to hereditary hypercoagulable state. Hence, the most likely diagnosis in this case was atrial myxoma. As the patient and her attendants were not willing for any invasive diagnostic procedure or intervention, TEE or biopsy could not be done.

The very late presentation in the eighth decade with a prolonged latent phase was very unique. Despite a ball valve phenomenon, there were no symptoms. More importantly, there was rapid deterioration of symptoms culminating in the loss of the patient. A chronic disease presenting acutely was a diagnostic serendipity.

   Conclusion Top

Left atrial myxomas can have varied clinical presentations, and local obstruction of mitral flow produces typical signs and symptoms. They can present as late as in the seventh decade and unless early surgical therapy initiated, it can prove fatal sometimes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Aggarwal SK, Barik R, Sarma TC, Iyer VR, Sai V, Mishra J, et al. Clinical presentation and investigation findings in cardiac myxomas: New insights from the developing world. Am Heart J 2007;154:1102-7.  Back to cited text no. 1
Amano J, Kono T, Wada Y, Zhang T, Koide N, Fujimori M, et al. Cardiac myxoma: Its origin and tumor characteristics. Ann Thorac Cardiovasc Surg 2003;9:215-21.  Back to cited text no. 2
Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Medicine (Baltimore) 2001;80:159-72.  Back to cited text no. 3
Gui J, Maqsood A, Khadka S, Rodriguez K, Everett G. New trend of cardiac myxoma-Case series and systematic review. Clinical Cardiology and Cardiovascular Medicine. 2015;101: 1-5.  Back to cited text no. 4
Mankad R, Herrmann J. Cardiac tumors: Echo assessment. Echo Res Pract 2016;3:R65-77.  Back to cited text no. 5
Yu K, Liu Y, Wang H, Hu S, Long C. Epidemiological and pathological characteristics of cardiac tumors: A clinical study of 242 cases. Interact Cardiovasc Thorac Surg 2007;6:636-9.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3]


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