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Management and Cesarean Delivery in a Parturient with a Right Atrial Mass
Abstract Number: F-30
Abstract Type: Case Report/Case Series
INTRODUCTION: Cardiac myxomas in pregnancy are a rare occurrence. Currently, of the 17 reported cases, 82% were left-sided and 65% were surgically excised prior to delivery(1). We present alternative management for a right-sided mass.
DESCRIPTION: A 31-year-old, G7P4025, parturient was referred for management of a right atrial mass. She suffered severe hyperemesis gravidarum requiring a central line for IV hydration. This was complicated by infection prompting a TTE that showed a right atrial mass. She was treated for sepsis and discharged with a PICC line for IV antibiotics and therapeutic enoxaparin. She presented to our institution at 29 weeks, after 4 weeks of antibiotics. Considerations included the mass’s etiology, timing of delivery, necessity of cardiac surgery, and risks of ongoing medical therapy. TEE during the admission showed a 2 cm pedunculated mass in the right atrium, attached to the anterior wall just superior to the tricuspid annulus, concerning for thrombus, vegetation or myxoma.
Anesthesiology consultation revealed shortness of breath with ambulation (starkly different than her four previous pregnancies), three-pillow orthopnea, and dizziness when standing. Her symptoms worsened with dehydration (a frequent complication of her hyperemesis). Exam revealed unlabored breathing, no JVD, and no peripheral edema. Vital signs (including orthostatics) and labs were normal.
A multidisciplinary team developed a plan to continue the pregnancy with anticoagulation, ongoing IV antibiotics, and frequent evaluations. During follow up, her symptoms were unchanged, she tolerated medical therapy, and the mass remained stable on TTE. At 37+3, amniocentesis demonstrated fetal lung maturity, enoxaparin was held, and a repeat c-section was performed under epidural anesthesia with arterial line monitoring and large bore IV access. Surgery proceeded uneventfully and a healthy baby girl was delivered. The patient remained hemodynamically and symptomatically stable throughout her recovery.
DISCUSSION: Our patient’s symptoms were concerning for hemodynamic manifestations of her intracardiac mass. Specifically, the positional characteristics most likely represented tricuspid obstruction from a volume or gravity dependent “ball valve” effect by the mass. However, these symptoms were confounded by her severe hyperemesis. The appearance of the mass favored a myxoma, but the presence of invasive lines and the procoagulant state of pregnancy also left a thrombus high on the differential. Conservative management was chosen, given the incidental discovery of the mass, uncertain etiology, close follow up plan, and stability of the mass on serial echocardiograms. The favorable maternal and fetal outcome suggests that there may be a subset of pregnant patients with intracardiac masses who may benefit from non-cardiac surgical management.
1. John AS, et al. Management of cardiac myxoma during pregnancy. Int J Cardiol. 2011Jun27. E-Pub.