This was a patient managed at the National Heart Hospital in Lusaka, Zambia.

1. PHYSIOTHERAPY MANAGEMENT
IN POST ATRIAL MYXOMA
EXCISION
PRESENTATION BY SPORAH CHISHA AND BENSON KAZEMBE

2. PRESENTATION
OUTLINE
• INTRODUCTION
• AETIOLOGY
• PREVALENCE
• PATHOPHYSIOLOGY
• CLINICAL FEATURES
• DIAGNOSIS
• MANAGEMENT
• COMPLICATIONS
• CASE
• DISCUSSION

3. Introduction
• Is a relatively rare type of cardiac tumor that develops in the heart's
atria (mostly left atria)
• Generally benign, but can impair heart function because of its
location.
• Mostly originate from the inter-atrial septum close to the fossa
ovalis and endocardium of the atrial septum (Baba A et al, 2022)

4. AETIOLOGY
• Myxoma cells originate from multipotent
mesenchymal cells
• 10% of myxomas are due to an inherited autosomal
dominant disorder called Carney's complex.
• The rest of the cases appears to be sporadic (Dergel
et al, 2022)
• The exact etiology of atrial myxoma is still under
investigation.

5. PREVALENCE
• Myxomas account for 40-50% of primary cardiac tumors
• Most common cardiac neoplasm with an estimated incidence of 0.5 –
1.0 per million cases per year (Fennira et al, 2019).
• Uchime et al, 2023 reported that its prevalence rate in the general
population is at 0.03%.

6. PATHOPHYSIOLOGY
• Myxomas are polypoid, round, or oval
out growth
• Gelatinous with a smooth or lobulated
surface and usually are white,
yellowish, or brown
• The most common site of attachment is
at the border of the fossa ovalis in the
left atrium

7. CLINICAL FEATURES
• May remain entirely asymptomatic, present with classical manifestations
or produce life-threatening emergency of systemic embolisation or even
sudden cardiac death
• Breathing difficulties when lying flat or on one side or the other
• Breathing difficulties when asleep
• Chest pain or tightness
• Dizziness

8. CLINICAL FEATURES CONT’D
• Syncope
• Heart palpitations
• Shortness of breath with activity / reduced cardiovascular endurance
• Symptoms due to embolism of tumor material
• Clinical examination may present cyanosis, clubbing or rash
• Neck veins may be engorged, and there may be a prominent A wave in the
jugular venous pulse

9. DIAGNOSIS
Diagnostic tests may include:
• Chest x-ray
• CT scan of chest
• ECG
• Echocardiogram
• Doppler study
• Heart MRI
• Heart angiography

10. MANAGEMENT
• This is achieved via a multidisplinary
wholistic approach which can be
classified into:
• Medical
• Surgical excision.
• Rehabilitative

11. MANAGEMENT CONT’D.
MEDICAL
• Medications may be used before and after surgery to manage symptoms
and reduce the risk of complications, they may include: Analgesics,
Antiarrythmias and Antihypertensives.
SURGICAL MANAGEMENT
• Myxoma surgical excision via median sternotomy is a primary
management
• This is a major open heart surgery under general anesthesia

12. REHABILITATIVE (PHYSIOTHERAPY)
PREOPERATIVE
• Important part of clinical preparation of the patient to undergo surgery and it
involves the following aspects:
• Assessment and evaluation – lung function test, cardiovascular endurance test
• Strength and endurance training
• Breathing exercises –if no risk of thrombus formation
• Patient education – procedure, sternotomy care, expectation, physio regimen

13. POSTOPERATIVE PHYSIOTHERAPY
MANAGEMENT
• Essential to promote patient's recovery and minimize complications
• Note that specific management plans may vary depending on the
patient's condition, surgical approach, and individual needs
• It's crucial to work closely with other team members in order come
up with beskope physiotherapy program for individual patients

14. POSTOPERATIVE PHYSIOTHERAPY CONT’D
• NOTE: monitor vitals (BP, pulse, SPo2,RR,CO2) cardiac monitor sounds
• Pay attentions to lines going into patient
• External pace maker
• From the word go, emphasize sternotomy incision site protection
• Gradual progression
• Early mobilization
• Chest physiotherapy
• Pain management

15. • Cardiopulmonary rehabilitation and endurance
• Edema management
• Pressure point care
• Functional rehabilitation
• Psychological support
• Education

16. COMPLICATIONS
• Congestive heart failure, Cardiac
arrhythmias
• Embolization, Finger clubbing
• Myocardial infarction, Pulmonary
edema
• Peripheral emboli
• Blockage of the heart valves

17. CASE
• NAME: E. C
• AGE AND GENDER: 44yrs, male
• OCCUPATION: Peasant farmer
• ADDRESS: Jazz compound, Kasama
• D.O.A: 06/06/2023
• WARD: Rehab II, room 203
• MAIN COMPLAINT:
1. Generalized body weakness
2. Pain in the bones
3. Bilateral pedal edema
NOTE: All symptoms/signs were
present for over 6 months

18. CASE CONTD.
• CASE HISTORY: Patient reported sudden onset of the above
symptoms. He sought medical attention at a local clinic where he
was prescribed analgesics and antibacterial drugs. The symptoms
would ease for a short while then they would be back. He
developed ascites and severe cardiovascular symptoms. Patient was
therefore referred to Kasama general and later to the National
Heart Hospital for further investigations and management.

19. • PAST MEDICAL HISTORY: none relating to the current condition
• DRUG HISTORY: Cephalexin, paracetamol and other unknown drugs
to the patient
• SOCIAL HISTORY: patient is married with 4 children, does not smoke,
quit drinking a year ago.

20. OBJECTIVE ASSESMENT
VITALS ON ASSESSMENT
• BP – 95/72 mmHg
• PULSE – 73 beats/minute
• TEMP – 35.6 degrees Celsius
• SpO2 – 99%
GENERAL OBSERVATION
• Ill looking, general body weakness
• Abdominal distension
• Biateral Pedal edema
LOCAL OBSERVATION
• Apical breathing

21. EXAMINATION CONTD.
PALPATION
• Bilateral pedal pitting edema
AUSCULTATIONS
• Reduced air entry on the left lung
NEUROLOGICAL TESTS
• Sensations, proprioception = intact
• Reflexes = Normal
MUSCLE POWER (OXFORD)
AND RANGE OF MOTION
• Reduced muscle power in all
muscle groups of the both
upper and lower limbs– 4/5
• Full range of motion all joints

22. RESPIRATORY AND CARDIOPULMONARY TESTS
PULMONARY LUNG FUNCTION
TEST (Spirometry)
• FEV1/FVC 1.48L/1.60L = 92.5%
• Inspiratory reserve volume (IRV)
= 1500cc
• Expiratory reserve volume (ERV)
= 1500cc.
CARDIOPULMONARY ENDURANCE STRESS
TEST (6MWT)
• Covered a distance of 296m in 6 minutes
• Rested once during the test
• Reason for resting was over exertion and
shortness of breath. Patient had Reduced
cardiopulmonary endurance

23. CLINICAL FINDINGS
1. Reduced cardiopulmonary
endurance
2. Easy fatigability
3. Generalized reduced muscle power
4. Bilateral Pedal edema
5. Ascites
6. Reduced air entry on the left lung
AIMS OF TREATMENT
1. Patient education on both pre
and postoperative
physiotherapy plans
2. Improve muscle power
3. Increase air entry
4. Educate patient on sternotomy
care and precautions.

24. PREOPERATIVE PHYSIOTHERAPY TREATMENT
• CHEST PHYSIOTHERAPY
N:B Patients with myxomas are advised not to do much pre operatively
because of fear of emboIi formation.
1. Education on Sternotomy care and precaution
2. Different types of chest expansion exercises i.e Combined deep breathes
with huffs and coughs
3. Incentivized Spirometry exercises
4. Mobilizing exercises, sitting and standing, ankle pumps

25. POSTOPERATIVE MANAGEMENT
• Patient underwent left atrial myxoma excision via midline sternotomy.
• Post-operative physiotherapy treatment began in the ICU within 24 hours of
extubation.
• DAY 1: Patient complained of general body weakness
• Vitals
• BP - 94/58 mmHg
• Pulse – 69 b/m
• SpO2- 95% on O2 two liters

26. POSTOPERATIVE MANAGEMENT CONT’D
• Day 0 to 1 regimen included; ankle pumps, hand grip exercises, facilitated
long sitting using a rope tied to the foot of the bed while supporting the
incision site with a small pillow.
• Percussions, coughing, huffing, and incentivized breathing exercises were
done.
• We progressed to placing the patient in high sitting on the bed and
performed active knee flexion and extension exercises.
• We progressed to ambulation on day 2, beginning with standing, marching
on the spot, and walking around the bed.
• Patient was very stable by day 5, he was able to walk independently and
hence was transferred to the ward where rehabilitation continued.
• He was discharged on the 10th day.

27. DISCUSSION
• Our patient presented with left atrial myxoma, which is a common
type of artria myxomas
• On physiotherapy preoperative assessment, the patient presented
with general body weakness, pedal oedema and was generally
looking ill and with ascites

28. • On examination, the findings were synonymous with Děrgel et al
(2022) who reported about difficulties in breathing while lying flat or
on exertion as seen in our patient with the following features
• Reduced IRV
• Reduced air entry
• Reduced cardiovascular endurance evidenced by reduced score in the
6MWT
• Erik et al, (2012) emphasized the importance of prevention of
postoperative complications by encouraging preoperative
physiotherapy regimen, which include assessment and evaluation of
the patient, education and chest physiotherapy.

29. • This is in tandem with our treatment protocol for E. M
• Our emphasis is not only on the chest physiotherapy exercises that the
patient will be engaged in postoperatively, but its also on precautionary
dos and don'ts for the sternotomy.
• Our protocol for postoperative management begins as early as possible
on day zero to promote early mobilization
• Attention and care is given to cardinal vitals, cardiac monitors as well as
all lines attached to the patient
• As the practice is world over (Melnyk et al, 2018)

30. CONCLUSION
• The patient progressed very fast such that
by day 5 they were out of step down ICU
to the main ward
• We continued physiotherapy on the ward,
till the patient was discharged and we
also referred for continued OPD
physiotherapy at his local hospital.