Syncope due to a silent mass

Abstract

A middle-aged man presented to the emergency department with syncope. Point-of-care echocardiography was performed and helped made the diagnosis. The patient thereby received the definitive treatment in the shortest possible time.

Case history

A 59-year-old man presented to the emergency department with first episode syncope. He was a construction site manual worker without any significant medical history apart from hypertension. His syncope lasted few minutes and was witnessed by his co-workers during the workers were doing routine stretching exercise in the morning right before starting to work. There were no prodromal symptoms; no chest pain, dyspnoea, dizziness, or neurological deficits. On examination, he was comfortable on the stretcher, afebrile, blood pressure 165/95 mmHg with pulse 83/min. His chest was clear and heart sounds were normal without murmurs; abdominal and neurological examinations were also unremarkable. Electrocardiogram (ECG), computed tomography (CT) brain and chest X-ray were all normal.

However, the patient’s troponin level resulted to be high, while his other lab tests were normal. He was reassessed but had no active complaints including chest pain. Repeated ECG was normal as well. A point-of-care (POC) transthoracic echocardiography (TTE) was therefore performed, which detected a striking abnormality (Figures 1 and 2).

Figure 1.

(a) A intracardiac mass on the parasternal long axis view; (b) same image with labels.

Figure 2.

(a) The same mass as seen on the apical four-chamber view; (b) same image with labels.

With the POC TTE findings, the cardiologist on call was immediately consulted, who did a formal TTE and communicated with the cardiothoracic surgeons. The patient finally had the mass excised the same night.

Questions

1. What are the echocardiographic findings?

2. What is the diagnosis?

3. What is the role of POC TTE on patients presenting with syncope?

Answers

1. A large mass was seen in the left atrium. It is irregular in shape, inhomogeneous and hyperechoic. It protrudes into the left ventricle and results in significant mitral inflow obstruction.

2. The echocardiographic findings are classical for an atrial myxoma.

3. Some culprit lesions or abnormalities can be seen by TTE, for example, obstructive masses, thrombus, right heart overload as a manifestation of massive pulmonary embolism, hypertrophic obstructive cardiomyopathy and many more.

Discussion

Cardiac myxomata are by far the most common mass lesions in the heart. They classically present with obstructive, embolic, or constitutional symptoms and are commonly found in the left atrium, usually attaching to the fossa ovalis. ¹ Despite the high troponin level of this patient triggered a TTE, cardiac enzymes typically are not high in patients with myxomata. ²

While a lot of patients present to the emergency department with syncope, not many of them are due to structural cardiac anomalies. Although it is quite clear that any positive physical or ECG findings such as murmurs and T wave abnormalities would necessitate a formal echocardiography examination, ³ the value of TTE for patients without such features (i.e. the ‘low risk’ group) is more controversial. Nevertheless, the patients’ care can be more streamlined and accelerated if any apparent findings are detected.