Title: A CASE OF RIGHT ATRIAL MYXOMA WITH SPECIAL REFERENCE TO AN UNUSUAL PHONOCARDIOGRAPHIC FINDING
Abstract: In this paper a case of myxoma of the right atrium successfully removed under hypothermia is described with an unusual phonocardiographic finding.The differential diagnosis of right atrial myxoma is briefly discussed. Case ReportA 49-year-old white woman was referred to the Cardiac Clinic of the Johannesburg Hospital on April 24, 1960.For 9 months she had had attacks of sudden pain in the right hypochondrium followed by extreme nausea, breathlessness and a feeling of faintness lasting up to 20 minutes.Breathlessness on exercise had also developed and just before admission she could walk only 50 yards.Her appetite had deteriorated and she had lost 40 lb. in weight.As recently as 3 years previously, her heart had been declared normal by several doctors who had examined her for minor ailments.On physical examination there was a malar flush with moderate cyanosis of the fingers, toes, lips, and cheeks.The blood pressure was 130/100 mm.Hg, with a mild continuous tachycardia (100 per minute).The jugular venous pressure though not elevated showed a large "a" wave.The heart was not clinically enlarged.On auscultation the first heart sound was very widely split with accentuation of the second (tricuspid) component.At the lower sternal area there was a low-pitched mid-diastolic murmur and an apparent presystolic murmur which extended up to tricuspid valve closure.Both murmurs increased in intensity on inspiration.At the base, both components of the second heart sound were audible but the pulmonary component was soft and was heard only in deep expiration and then with difficulty.The liver was palpable two fingers' breadths below the right costal margin.The central nervous and respiratory systems were normal.On fluoroscopy the pulmonary vasculature was normal, there was no cardiomegaly (cardio-thoracic ratio 48%) but prominence of the right heart border was suggestive of some right atrial dilatation.An electrocardiogram showed a generalized low voltage, a P-R interval of 0-19 seconds and no P wave enlargement.Flattened T waves and sagging S-T segments in leads II, III, AVF, and V4-6 were compatible with myocardial ischTmia.The clinical picture was thus suggestive of isolated tricuspid stenosis or obstruction which, from the history, was of recent onset and rapidly progressive.An intracardiac neoplasm, causing obstruction at the tricuspid valve orifice, seemed the likely diagnosis.Special Investigations.Hemoglobin was 13-4 g. per cent, white cell count 8-300 per c.mm., sedi- mentation rate (3 tests) 4-15 mm. in 1st hour (Wintrobe).The C-reactive protein was positive (+ + + +) and the urine was normal.