Cardiac myxoma is a benign tumor, but it is known for its space-occupying effect at the site of origin and frequent systemic embolization. This case report highlights a biatrial myxoma of interatrial septum who presented with significant tricuspid valve regurgitation, atrial fibrillation, and cardioembolic stroke of the left parietal lobe, i.e., a biatrial myxoma with triple ripples.

1. © 2018 Journal of Cardiovascular Echography | Published by Wolters Kluwer - Medknow 59
Abstract
Case Report
Introduction
Cardiac myxoma is found most commonly in adult females.
The median age at presentation is about 49 years, with wide
range in the age of presentation from below the age of 20 years
to >90 years. Left atrium is the most common site.About 90%
of myxomas are solitary. Biatrial myxoma is rare. Clinical
suspicion is difficult because of nonspecific clinical features
such as fever, myalgia, abnormal heart sounds, murmurs, and
cardioembolic stroke. Echocardiography is reputed for its high
sensitive of detection of cardiac myxomas.
Case Report
A 69‑year‑old female had a massive cardioembolic stroke in
the left parietal lobe 2 months earlier. There was a significant
improvement of classical right‑sided hemiplegia by the time
of presentation to us. She was taking acenocoumarol 2 mg
once daily, oral glycerin 30 ml three times daily., phenytoin
100 mg t. i. d., and small dose of loop diuretic. A 12‑lead
electrocardiogram showed atrial fibrillation. Transthoracic
echocardiogram and transesophageal echocardiogram
unanimously disclosed a classical butterfly wing (so‑called
dumbbell shaped) intracardiac myxoma with moderate
tricuspid valve regurgitation due to direct impingement on
tricuspid valve [Figure 1 and Video 1]. There was no satellite
focus. Routine workup showed normal leukocyte count,
hematocrit, erythrocyte sedimentation rate, coagulation
profile, kidney function test, thyroid function test, normal
blood glucose level, and normal chest X‑ray. Arecent 16‑slice
computed tomography (CT) scan with contrast enhancement
showed large left parietal lobe of cerebral contrast‑enhancing
space‑occupying lesion with midline shift. She was successfully
operated for myxoma. The gross pathology of resected bilobed
tumor had size of 4 cm × 2 cm with smooth and jelly‑like
surface with foci of hemorrhage and calcification [Figure 2].
Histopathology using hematoxylin–eosin staining of the
excised tumor revealed spindle‑shaped cells in a loose myxoid
stroma, consistent with the diagnosis of myxoma.
Discussion
A dumbbell or butterfly wing or so‑called biatrial myxoma or
interatrial septal myxoma with biatrial extension usually arises
from the left atrial side of the fossa ovalis and prolapses into the
right atrium through foramen ovale.[1]
Its incidence is <1%–5%
of all the intracardiac myxomas.[2‑4]
Although it is benign, it is
well known for its local space‑occupying effect and systemic
embolization.A close differential diagnosis is biatrial thrombus
crossing a patent foramen ovale, but either biatrial myxoma or
straddling thrombus through foramen ovale is a rare diagnosis.[5]
Thrombus in this situation may have identifiable causes such
as deep vein thrombosis, metastasis, and mitral stenosis.[6]
Thrombus is more irregular in shape. Intracardiac thrombus
Cardiac myxoma is a benign tumor, but it is known for its space‑occupying effect at the site of origin and frequent systemic embolization. This
case report highlights a biatrial myxoma of interatrial septum who presented with significant tricuspid valve regurgitation, atrial fibrillation,
and cardioembolic stroke of the left parietal lobe, i.e., a biatrial myxoma with triple ripples.
Keywords: Atrial fibrillation, biatrial myxoma, embolic stroke, tricuspid valve regurgitation
Address for correspondence: Dr. Ramachandra Barik,
All India Institute of Medical Sciences, Bhubaneswar ‑ 751 019,
Odisha, India.
E‑mail: cardioramachandra@gmail.com
A Biatrial Myxoma with Triple Ripples
Ramachandra Barik
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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How to cite this article: Barik R. A biatrial myxoma with triple ripples. J
Cardiovasc Echography 2018;28:59-60.
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2. Barik: Triple ripples of a bi-atrial myxoma
Journal of Cardiovascular Echography ¦ Volume 28 ¦ Issue 1 ¦ January - March 201860
being more fragile usually presents with evidence of pulmonary,
systemic embolism, and coronary embolism.[7]
It should be
removed by wide base resection as soon as possible because
of higher frequency of embolization.[8]
Echocardiography gives
significant number of clues such as the polypoid or smooth
surface myxoma, the site of origin, satellite focus, and diastolic
blockage of mitral or tricuspid inflow which almost support
provisional diagnosis of cardiac myxoma.[9]
Contrast‑enhanced
CT scan of chest or lung scintigraphy would have provided
the evidence of silent concomitant pulmonary embolism but
has not been done in our case neither before surgery nor after
surgery because there was no evidence of pulmonary arterial
hypertension and financial limitation.
Conclusion
Impingement of tricuspid valve causing tricuspid valve
regurgitation, atrial fibrillation, and cardioembolic stroke was
triple ripples of dumbbell‑shaped cardiac myxoma.
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Figure 1: Transthoracic echocardiography in 4‑chamber views showed a
classical dumbbell‑shaped myxoma of 4.1 cm × 3.1 cm sized across the
interatrial septum through the foramen ovale. Some specks of hyperechoic
spots were marked possibly due to calcification
Figure 2: The excised tumor mass consisted of 4.1 cm × 3.1 cm
mobile right and left atrial myxomas connected by a common stalk
which passed through the atrial septum, collectively resembling the
shape of a dumbbell (butterfly). Smooth and jelly‑like surface with foci
of hemorrhage was evident
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