A rare case of right ventricular myxoma causing recurrent stroke

Mechanical Thrombectomy for Acute Ischemic Stroke in Patients With Cardiac Myxoma: A Case Series and Pooled Analysis

Background and Purpose

Acute ischemic stroke (AIS) is a common and life-threatening complication of patients with cardiac myxoma (CM). The role of the mechanical thrombectomy (MT) technique in CM-AIS patients remains unclear, and no guidelines exist for this population. Therefore, we conducted a case series study of MT in CM-AIS patients to investigate its safety and efficacy via a pooled analysis of published literature.

Methods

Eleven CM-AIS patients who underwent MT between 2016 and 2021 were screened from multicenter stroke databases. Clinical, procedural, and outcome data were obtained from medical records. A systematic review was conducted to identify additional cases from published studies by searching PubMed and China National Knowledge Infrastructure databases. We then performed a pooled analysis of the published cases.

Results

In the case series study, most patients were male (81.8%), with a median age of 51 years. All patients had CM located in the left atrium. The rate of successful reperfusion using the first-line thrombectomy technique was 100% with stent retriever (SR) and 66.7% with direct aspiration (DA), which resulted in overall successful reperfusion in 94.1% of all occlusions. The retrieved emboli of the five patients who underwent histopathology examination were identified as myxoma components. Hemorrhagic transformation was observed in five (45.5%) patients, of whom one was symptomatic (9.1%). Three-month favorable functional outcomes were achieved in five (45.5%) patients with a 3-month mortality rate of 18.2%. For the literature review, 35 cases with 51 target vessel occlusions were identified and included in the pooled analysis. The rate of successful reperfusion following first-line thrombectomy did not differ between SR (30 patients, 90.9%) and DA (10 patients, 83.3%). The overall successful reperfusion rate was 91.8% of all occlusions. Three-month favorable functional outcomes were achieved in 21 (60.0%) patients, and the mortality rate was 8.6%.

Conclusions

Our findings suggest that MT is not only an effective technique but also a safe option for CM-AIS patients with large vessel occlusion. MT has several advantages for this population, which include a high recanalization rate, low bleeding risk, and the ability to evaluate the source of emboli and the etiology of stroke.

Right Ventricular Outflow Tract Obstruction in Adults: A Systematic Review and Meta-analysis

Background

Right ventricular outflow tract obstruction (RVOTO) is a cause of hemodynamic instability that can occur in several situations, including cardiac surgery, lung transplantation, and thoracic surgery, and in critically ill patients. The timely diagnosis of RVOTO is important because it requires specific considerations, including the adverse effects of positive inotropes, and depending on the etiology, the requirement for urgent surgical intervention.

Methods

The objective of this systematic review and meta-analysis was to determine the prevalence of RVOTO in adult patients, and the distribution of all reported cases by etiology.

Results

Of 233 available reports, there were 229 case reports or series, and 4 retrospective cohort studies, with one study also reporting a prospective cohort. Of 291 reported cases of RVOTO, 61 (21%) were congenital, 56 (19%) were iatrogenic, and 174 (60%) were neither congenital nor iatrogenic (including intracardiac tumour). The mechanism of RVOTO was an intrinsic obstruction in 169 cases (58%), and an extrinsic obstruction in 122 cases (42%). A mechanical obstruction causing RVOTO was present in 262 cases (90%), and 29 cases of dynamic RVOTO (10%) were reported. In the 5 included cohorts, with a total of 1122 patients, the overall prevalence was estimated to be 4.0% (1%-9%).

Conclusions

RVOTO, though rare, remains clinically important, and therefore, multicentre studies are warranted to better understand the prevalence, causes, and consequences of RVOTO.

Intravenous thrombolysis for pure pontine infarcts caused by cardiac myxoma: a case report and literature review

Purpose: Cardiac myxoma (CM) is a rare but important cause of ischemic stroke, and typically involves the middle cerebral artery and rarely affects the brainstem only. The safety and efficacy of intravenous thrombolysis (IVT) for CM-related acute cerebral embolism are not clear.Methods: We report a case of a 55-year-old woman who suffered a CM-related acute cerebral embolism presented with pure pontine infarcts and achieved a favorable prognosis by IVT with urokinase. We summarized the clinical data of this entity and performed a literature review of 21 previous reports of patients with CM-related acute cerebral embolism who were treated with IVT.Results: In combination with previous reports, we found that the majority of patients (81.8%) obtained improvements in symptoms after IVT, including 63.6% in remarkable clinical improvement. The total rate of IVT-induced intracerebral hemorrhage was 22.7% and all occurred within 36 h, including hemorrhagic infarction type 1 (4.5%) and parenchymal hematoma type 2 (18.2%). Most of the cases had relatively good outcomes and no case died due to IVT.Conclusion: Taken together, our findings support the use of IVT as an effective and safe tool for the ultra-early treatment of CM-related acute phase ischemic stroke.

Unusual aspects of cardiac myxoma

A cardiac myxoma may manifest as miscellaneous and uncharacteristic presentations. These unusual aspects of cardiac myxomas can be rare clinical presentations, special patient populations, unusual locations, and special pathology, which may lead to a delayed diagnosis, improper checkups, and subsequent untimely treatment, eventually resulting in unexpected poor prognosis. Therefore, the diagnosis of cardiac myxomas can be challenging because of these unusual aspects. In order to get a better understanding of a cardiac myxoma and to facilitate an early diagnosis and proper treatment, the unusual aspects of cardiac myxomas are described here.

Established and potential echocardiographic markers of embolism and their therapeutic implications in patients with ischemic stroke

Cardiogenic strokes comprised 11% of all strokes and 25% of ischemic strokes. An accurate identification of the cause of stroke is necessary in order to prepare an adequate preventive strategy. In this review the confirmed and potential causes of embolic strokes are presented, which can be detected in echocardiography in the context of present treatment guidelines and gaps in evidence. There remains a need for further studies assessing the meaning of potential cardiac sources of embolism and establishment of rules for optimal medical prevention (antiplatelet therapy [APT] vs. oral anticoagulation [OAC]) and interventional procedures to reduce the incidence of ischemic strokes. Currently available data does not provide definitive evidence on the comparative benefits of OAC vs. APT in patients with cryptogenic stroke or embolic stroke of undetermined source. There is a lack of antithrombotic treatment scheme in the time between stroke and the completed diagnosis of potential sources of thromboembolism.