Expectorate the unexpected

A 43-year-old man underwent a computed tomography pulmonary angiography for suspected pulmonary embolism after he presented with an episode of orthopnoea associated with blood-stained expectorate. The only finding was a left atrial mass (Figure, A, arrow). Further history revealed 6 months of progressive postural presyncope, malaise and weight loss of 3 kg.

Echocardiography showed a circumscribed 7.0 × 4.5 cm heterogeneous mass, with areas of cystic degeneration (Figure, B, yellow arrows) and frond-like extensions (∼ 3 mm; Figure, B, red arrow), consistent with a myxoma. The mass was attached to the interatrial septum via a small stalk and prolapsed through the mitral valve, causing significant mitral inlet obstruction; the mean gradient was approximately 12 mmHg (Figure, C). The mass was successfully removed (Figure, D).

Figure

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LA = left atrium. LV = left ventricle. RA = right atrium. RV = right ventricle.