This patient was operated by Prof. M. A. Quashem, Professor and Head, Department of Cardiac Surgery, NICVD, Dhaka, Bangladesh.

1. CASE PRESENTATION
RA MYXOMA
Presenter:
Dr. Hriday Ranjan Roy
Consultant, Surgery
Rangpur Medical
College Hospital

2. THE EVER LARGEST RIGHT
ATRIAL MYXOMA IN NICVD
RA MYXOMA

3. Mr. Jalal Ahmed- 45 years, a cultivator, hailing
from Cox’s Bazar admitted into NICVD on
21/11/2006 with the complaints of-
1) Intermittent Syncopal attack for 1 month
2) Dyspnoea for 11/2 months
3) Constitutional symptoms for 2 months

4. The presenting complaints was first noticed
by him 2 months back with low grade
fever- which was irregular and was not
associated with cough or hemoptysis. He
also developed headache, malaise and
some sorts of neurological dysfunction.
For the last 11/2 months, he developed
dysponoea- mostly while he lie on bed, but
did not relieve by sitting upright. It also
occasionally aggravated by exertion. He
has no H/O of asthma or tuberculosis.

5. During last 1 month, he began to have Syncopal
attack 2/3 times a day. Very occasionally, it
was associated with convulsion, palpitation
and tightness of chest. He has no H/O DM,
HTN or smoking.
For these above complaints, he was admitted
into Cittagong Medical College Hospital on
5/11/2006 and was treated by anti-epileptic
drugs (Discharge Certificate contains no
information). But as the symptoms did not
improve, he was referred to DMCH on
14/11/2006.

6. The diagnostic work out done in
DMCH were1) CBC- Hb-13.6 gm%, ESR-58, TC-11,500
DC- N-90%, L-8%.
2) RBS- 4 mmol/L
3) SGPT- 25 U/L
4) S. Billirubin- 1.16 mg%
5) S. Creatinine- 1.64 mg%
6) CXR- normal
7) ICT for malaria- negative
8) CT scan of brain- normal

7. With the above scenario, he was empirically
diagnosed as a case of cerebral malaria
and was treated as such ( Inj- Jasoquine).
But as the symptoms did not improve, an
echo was done and was diagnosed as a
case of RA myxoma and was referred to
NICVD on 21/11/2006.

8. General examination on
admission (in NICVD)Appearance- ill looking, confused.
P- 100/min
B.P- 100/70 mmHg
Neck veins- engorged
Heart- Diastolic murmur at tricuspid area,
localized.
Lung- clear
No jaundice, edema, enlarged L. nodes or
clubbing.
P/A- normal.

9. Reevaluation was done in Cardiology
Unit-I on 23/11/2006 as followsCXR

10. ECG

11. Echo ( Done by Dr. Mazhar-AP)AP4CH, 2D

12. Other baseline investigations was
within normal limits
He was then submitted urgently to SU-III for
emergency surgery.
On 25/11/2006, Under G/A with CPB, open
heart surgery was performed.
ECCT was 96 min, XCT- 52 min.

13. Per-operative findings and
procedures wereA huge ( 9cm × 7cm) encapsulated mass,
occupying 2/3rd in RA and 1/3rd in RV and
was protruding into RVOT (as in Echo).
It was attached to the limbus of fossa ovalis
by a narrow stalk. Careful removal of the
mass was done to avoid pulmonary
embolism.

14. Stages of Operation (Bypass
established, RA- dilated)

15. The mass is being delivered after
RAtomy

16. The mass is being separated

17. RA cavity after removal of the
mass

18. Video Show of the surgery
Per Op Video.3gp

19. Photographs of the Mass after
removal

20. Mass ( Cont…)

21. Mass ( Cont…)

22. Regurgitant test was done.
TV regurgitation G-IV,

23. The annulus of the TV was found
to be dilated with TR G-IV
De Vega annuloplasty was done by 3/0 plolene.

24. De Vega (Cont….)

25. Post operative periodExtubation was done on 26/11/2006 morning with
smooth ICU outcome. Some sorts of inotropic
support was needed( Dopa, Dobuta) for 2/3
days.

26. Histopathology Report
Consistent with myxoma

27. Histopathology Report (Cont..)

28. Histopathology Report (Cont..)

29. Post operative echo

30. Post operative echo cont….
Normal LV function
Mild septal hypokinesia
Tricuspid regurgitation Grade-II

31. Post operative pulmonary functionHeight- 170cm, Weight- 50 Kg
Variables
VC (L)
FVC (L)
FEV1 (L)
FEV1(%)
PEF (L/s)
MVV (L/m)
Measured
4.01
3.59
3.37
93.87
9.72
59.9
Predicted
4.23
4.23
3.48
82.55
8.41
148.8
% Predicted
94.8
84.9
96.8
113.71
115.6
40.3
Comment- Normal pulmonary function

32. Personnel involved in treatment:
Cardiology Unit-I
Prof. A. A. Shafi Majumder and his
team.
Surgery Unit-III
Prof. M. Abul Quashem and his
team.

33. The final situation of the patient
Every parameters
are good.
Neurological
symptoms has
been
disappeared.
He is feeling well.

34. He is smiling
The gentleman’s smile is valued
trillion dollars to us.

35. THANK YOU ALL