Case Presentation
A 58 years old female presented with a 2-month history of dyspnea on
exertion (DOE) and two episodes of
syncope was admitted on January
20th, 2020. The transthoracic echocardiography (TTE)
showed a well-defined heterogeneous large round mobile mass with
attachment to the atrial side of anterior mitral valve leaflet (AMVL)
(29*20mm) suggestive of an atypical myxoma (Figure 1). In addition, the
Ejection Fraction (EF) of 55%, severe mitral stenosis, severe mitral
regurgitation, mild to moderate tricuspid regurgitation, and pulmonary
arterial systolic pressure (PASP) of 42 mmHg were reported. The coronary
angiography revealed normal epicardial coronary arteries. The brain CT
and neurologic evaluation results were unremarkable. The patient became
a candidate for surgical mass excision. On January
24th, the LA
mass was removed completely (2*2.5 cm) and the mitral valve was replaced
with the St. Jude Medical prosthesis due to the involvement of AMVL. The
histopathological examination revealed diffuse fibrosis of mitral valve
and cellular pleomorphism and high mitotic activity in the removed
cardiac tumor. The evaluation of the surgical margin was not possible.
Postoperative echocardiography revealed that the prosthetic valve had
good leaflet motion with an acceptable gradient. The EF of 45%, Mild
TR, and PASP of 28mmHg were also reported. No residual mass was
detected. The patient was discharged thereafter on February
3rd.
Seventy-nine days later on April 22nd, 2020, the
patient was readmitted with a 1-week history of
dyspnea, palpitation, fever (body
temperature of 38 °C), and sore throat. The
time
in therapeutic range assessment revealed that the international
normalized ratio (INR) was acceptable during the mentioned period. In
the emergency department, the TTE revealed fixation of one of leaflet of
the prosthetic mitral valve with a mean pressure gradient of 12 mmHg,
LVEF of 50%, moderate to severe TR and PASP of 63 mmHg. The mitral
valve fixation was evident in the fluoroscopy. Laboratory examination
demonstrated the high sensitive C-reactive protein (hs-CRP) of 9.9 mg/dl
and white blood cell of 7100/μL with lymphocyte percentage of 18.8%. In
the COVID-19 pandemic era, the focus was diverted to the thrombotic
event of the prosthetic valve in the context of coronavirus infection
and a spiral chest computed tomography (CT) scan performed to exclude
the lung involvement. Although, no evidence of COVID-19 was detected in
chest CT except mild pleural effusion, empiric antiviral treatment with
hydroxychloroquine and azithromycin was initiated with respect to
symptoms and high hs-CRP. The blood culture examination result was
negative. The transesophageal echocardiography (TEE) revealed a very
large non-homogenous LA mass (4*4cm) on the lateral LA wall that seemed
to be an organized thrombus and
restricted mitral valve leaflet motion (Figure 2). The reverse
transcription-polymerase chain reaction test was negative for COVID-19.
The patient was a candidate for surgical removal of the mass which was
thought to be a thrombus (4*4 cm). Surgical resection of the mass was
done on 27th April and the gross appearance was not
compatible with thrombus or pannus. The postoperative echocardiography
on May 2nd revealed LVEF of 40%, good leaflet motion
of the prosthetic mitral valve. No visible residual mass was detected.
The operative specimen was sent for pathological assessment. The
Immunohistochemical stain raised the diagnosis of liposarcoma. The
primary origin of the tumor approved, hence, the patient referred to the
oncology department.