Cardiology in Review
Volume 11, Number 1, pp. 41–44
Copyright © 2003 Lippincott Williams & Wilkins

Clinical Case

Left Hemiparesis from Atrial Myxoma Emboli
Finalist, Cardiology in Review Fellowship/Residency Clinical Case Contest
BRIAN D. LE, MD,* JAMES A. DE LEMOS, MD,† MICHAEL A. WAIT, MD,‡ GARY GOFF, MD,§
JAMES BOEHRER, MD,¶ and GAIL E. PETERSON, MD†
Atrial Myxomas are benign primary tumors of the heart, arising mainly from the left
atrium. Clinical signs and symptoms produced by atrial myxomas may be non-specific or
result in mechanical obstruction of cardiac function, arrhythmias, and embolization. The
authors present a case of a 60-year-old woman who developed total left hemiparesis
resulting from left atrial myxoma embolization causing complete occlusion of the right
middle cerebral artery.
Key Words: Atrial myxoma, Stroke, Embolization, Cardiac tumors, Benign tumors,
Familial tumors.

Primary tumors of the heart are rare entities, occurring in 0.05% of patients at necropsy (1). Myxomas are the most common tumors of the heart,
representing 83% of primary cardiac tumors (2).
Myxomas overwhelmingly affect adults, whereas
rhabdomyomas are most commonly found in children (3). Histologically, cardiac myxomas are benign, but they can be lethal based on their anatomic location. The symptoms depend on size,
mobility, and location of the tumor. Most patients
present with one or more of the quatrad of embolism, intracardiac obstruction, constitutional
symptoms, and arrhythmias (4).
We report a case of a 60-year-old female who
presented with a dense left hemiparesis. She was
later found to have a left atrial myxoma that embolized to the right middle cerebral artery, resulting in cerebral infarction.

CASE REPORT
A 60-year-old black woman presented to the
emergency room complaining of an inability to
*Cardiology Fellow, †Assistant Professor, Department of Cardiology,
‡Associate Professor, Department of Cardiothoracic Surgery, University
of Texas Southwestern, Dallas, Texas; §Internal Medicine, and ¶Cardiologist, St. Paul University Hospital, Dallas, Texas.
Address reprint requests to: Gail E. Peterson, MD, 5323 Harry Hines Blvd.,
Dallas, TX 75390-9047. E-mail: gail.peterson@utsouthwestern.edu.

Volume 11, Number 1, 2003

move the left side of her body. The night before
admission, she experienced severe left arm pain.
On awakening in the morning, she developed
paralysis of the left upper and lower limbs. She
denied numbness, visual changes, headaches, or
dysarthria.
Her medical history was significant for longstanding hypertension. She had no history of tobacco, alcohol, or illicit drug abuse. Family history was notable for a mother who died from a
myocardial infarction at the age of 83 and a father
with longstanding hypertension.
On admission, the patient has a temperature of
97.4°F, a heart rate of 98 beats/min, a blood pressure of 156/87 mm Hg, and a respiratory rate of
16/min breathing room air. Physical examination
revealed an alert and oriented woman. She had no
jugular venous distention, and her carotid impulse was normal, without bruits. Lungs were
clear to auscultation. Cardiac examination revealed a regular rhythm and rate; a loud, widely
split S1; and no murmurs or extra heart sounds.
She had no lower extremity edema. Her neurologic exam was significant for a right gaze preference and a left facial droop. She neglected her left
side. Otherwise, her cranial nerves were intact.
She had 0/5 motor strength on the left and normal
strength on the right. Her sensation was intact.
Deep tendon reflexes were 2⫹ bilaterally. Babinski was downgoing on the right and equivocal on
CARDIOLOGY IN REVIEW

41

the left. She had no clonus and a negative Hoffman’s sign.
Her laboratory evaluation was normal with the
exception of a potassium concentration of 3.0
mEq/L. Her lipid panel was normal, with an LDL
of 89 mg/dL and an HDL of 67 mg/dL. Electrocardiogram revealed normal sinus rhythm. Chest radiograph showed normal cardiac silhouette without masses or infiltrates. Head CT obtained in the
emergency department revealed acute infarction
of the right temporal lobe cortex and right cerebellar hemisphere without intracranial hemorrhage.
The patient was started on aspirin and Plavix
(Sanofi Winthrop Pharmaceuticals, New York,
NY). Low-dose ACE inhibitor was initiated for
titration of blood pressure. The following day, an
MRI scan of the brain confirmed acute infarction
in the right basal ganglia and internal capsule
with smaller foci of infarction in the right temporal lobe and right cerebellar hemisphere (Fig. 1). A
magnetic resonance angiogram revealed complete
occlusion of the right middle cerebral artery at its
origin without extracranial cerebrovascular stenosis (Fig. 2). Carotid Doppler studies confirmed
normal extracranial vessels. A transthoracic echocardiogram demonstrated a large, 9-cm ⫻ 3-cm
left atrial mass arising from the interatrial septum
and prolapsing into the left ventricle through the
mitral valve, consistent with a myxoma (Fig. 3).
The patient was scheduled for surgery in 10 days
to allow healing of her cerebral infarcts before
undergoing cardiopulmonary bypass. On the fifth
hospital day, the patient developed altered mental
status with worsened left gaze deviation, worrisome for another cerebral embolus. A repeat head
CT and MRI failed to reveal any new cerebral
lesions. The patient underwent cardiac catheterization on the same day, which revealed normal
coronary anatomy. The next morning, she underwent successful surgical resection of the left atrial
mass. Biopsy of the mass confirmed a smooth,
gelatinous atrial myxoma (Figs. 4 and 5). She had
an uneventful recovery with resolution of her
right gaze preference and left-sided neglect. Despite intensive physical rehabilitation, she had no
improvement in her left hemiparesis.

DISCUSSION
Atrial myxomas occur more commonly in
women (3:1 ratio) and are usually diagnosed between the ages of 50 and 70 years. Approximately
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Figure 1. Magnetic resonance imaging showing acute
infarctions in the right temporal lobe and internal
capsule. Cerebellar and basal ganglia infarctions are not
depicted on this image.

75% originate in the left atrium and 15 to 20% in
the right atrium. Only 3 to 4% are detected in the
left or right ventricle (4,5). The majority are attached to the left atrial septum around the fossa
ovalis, occasionally with a component protruding
through the atrial septum to the right side. Ninety
percent of atrial myxomas are solitary tumors that
occur without obvious genetic predisposition. In
contrast, multiple atrial myxomas that are associated with facial freckling and endocrine adenoma
form a syndrome termed the Carney complex.
This complex is named for the physician who first
described the heritable nature of this disorder (6).
Familial myxomas occur in younger patients, and
screening of first-degree relatives should be performed.
Myxomas are neoplasms arising from the endocardium. Although not well studied, the rate of
growth appears to be relatively rapid compared
with other benign neoplasms (7). The majority of
myxomas are pedunculated, with a smooth, gelatinous surface. The less common villous or papillary myxomas account for approximately one
Left Hemiparesis from Atrial Myxoma Emboli

Figure 4. Transesophageal echocardiogram depicting the
0.5-cm stalk of the left atrial myxoma originating from
the fossa ovalis (white arrow).

Figure 2. Magnetic resonance angiogram revealing
complete occlusion of the right middle cerebral artery at
its origin (white arrow).

Figure 5. Gross specimen of the excised left atrial
myxoma.

Figure 3. Transthoracic echocardiogram showing 9-cm ⫻
3-cm left atrial myxoma extending from the left atrium
into the left ventricle (white arrow).

third of cases and are more friable and fragile,
with a tendency to fragment spontaneously (4).
Our case was unusual in that the left atrial myxoma was nonvillous with a smooth contour, yet
underwent embolization.
Volume 11, Number 1, 2003

Embolism occurs in 10 to 45% of patients with
myxomas (2,4,8,9). Since myxomas most commonly arise from the left atrium, systemic embolism is frequent. The majority of cases occur in the
cerebral and retinal arteries. Other sites reported
include peripheral, aortic, renal, and visceral vessels. In right-sided myxomas, clinically evident
embolism is uncommon. However, pulmonary
vessel embolism resulting in pulmonary hypertension has been reported (10).
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Other clinical presentations include symptoms
resulting from obstruction in ventricular inflow,
depending on the size of the myxoma. Symptoms
include dyspnea, recurrent pulmonary edema,
and right heart failure mimicking tricuspid and
mitral stenosis. If complete obstruction occurs,
syncope and sudden death may ensue. The extent
of valvular obstruction may vary with body position (11–13). Atrioventricular block and ventricular tachycardia may be seen from infiltration of
the conduction tissue or irritation of the myocardium itself. Lastly, constitutional symptoms of
fever, rash, weight loss, fatigue, and myalgia or
arthralgia along with anemia and elevated CRP,
ESR, and globulin fraction have been noted in
many patients, regardless of the size of the tumor.
Systolic and diastolic murmurs are heard in
over 50% of patients with myxomas. Murmurs
vary according to size, location, mobility of the
tumor, and body position. In one third of the
patients, a diastolic murmur can be heard 80 to
150 milliseconds after the second heart sound;
this sound has been termed the tumor plop. In
patients with left atrial myxomas, the first heart
sound is often loud and widely split due to the
delay in mitral valve closure from tumor obstruction (10,14). This finding was noted in our patient.
The diagnosis can be made reliably with transthoracic echocardiography. Echocardiography
can determine the location, size, shape, and mobility of the myxoma. Transesophageal echocardiography may be a useful adjunct in detecting the
site of insertion and morphologic features of myxomas. The sensitivity of transthoracic echocardiography is 95.2% and TEE 100%, compared to
70% by CT and MRI (15). Unlike ultrasound, CT
and MRI may help differentiate tissue composition.
The treatment of choice for atrial myxomas is
early surgical resection, which is usually curative.
Coronary arteriography in patients over 40 years
of age is generally required to rule out concomitant coronary artery disease before undergoing
surgery. Surgery is performed to prevent embolic
complications and sudden death. The root of the
pedicle and the full thickness of the adjacent
interatrial septum should be excised, with the
resulting atrial defect closed with a pericardial or

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Dacron patch if the defect is sufficiently large.
Hospital mortality was 3.7% in one series, with a
recurrence rate of 4.7% (16,17). The recurrence
rate for sporadic myxomas is 1 to 3%; in contrast,
the recurrence rate with familial myxomas is at
least threefold higher (18). Nevertheless, longterm follow-up with echocardiography is recommended in all cases.

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Left Hemiparesis from Atrial Myxoma Emboli