A lady with acute SOBSammi Pe

Case Presentation54/FCat IIBP 129/69mmHg P 128Temp 36.9 SpO2 78% ( 100% O2)Triage : SOB since afternoon, cough with sputum, mild chest discomfort

What will you do ?What further history need?

What further Hx Good Past HealthDomestic helperSOB since ~2 hrs agoMild cough with yellowish sputum xdays become blood stained on AEDNo fever Chest discomfort today ( tightness)Palpitation +ve

More hx from employerMild exertional SOB x several daysNeed resting after her workNo fever all alongNo Travel hxWork in HK x ~17yrsNo GI upset/ abd painNot on regular medication Non-smoker, non-drinker

P/EAlert GCS 15/15BP 139/78 P 120RR 48Sit up for breathingSpO2 80% on 100% O2Recheck Temp 37.2Hstix 13.2

P/E Chest: AE fair with bilateral basal crep, occ wheezeAbd softHS dual, no murmurNo ankle edema

What will you do next ?

ABC100% O2 maskHB setBlood x CBC, L/RFT, Trop I , ClottingECG i stat ( arterial) CXR

ECG x 2

i stat (arterial, on 100%O2)pH 7.398pCO2 5.39 kPapO2 5.8 kPaBE 0HCO3 24.9 mmol/LSO2 79%Na 141 K 3.5 i Ca 1.21 Hb 14.6

Our PatientProblem:Sudden onset SOBDesaturation even on 100% O2Type I Resp Failure

What is yr DDx?

Type I Resp FailureTypically due to V/Q mismatch PaO2 low (< 60mmHg(8.0kPa)) PaCO2 normal or low PA-aO2 increasedParenchymal disease (V/Q mismatch) Diseases of vasculature and shunts: right-to-left shunt, pulmonary embolism interstitial lung diseases: ARDS, pneumonia, emphysema.

Patient was still in distress even on 100% O2What will you do then?

Patient was put on CPAPLasix 40mg iv

BP 110/70 Clinically improved

CXR film A/V.

CXRWhat is yrDiagnosis?

APO . ? Other drug(s) to be considered? Underlying cause

CCU was consulted

MedicationsNitratesVasodilationReduced preload and afterloadImproved CORapid effectNot prescribed likely due to BP on low sideDiureticsReduced plasma volume / preloadPulmonary vasodilatation

ACEIReduced afterloadImproved CO

Underlying CausesACSHTAortic/mitral valve diseaseArrhythmias

VSD CardiomyopathyAcute myocarditisPericardial diseaseAtrial myxoma

Echo was performed

Our case

What is show in the Echocardiogram?

CCU inputECHO: LA mass ~4cmLikely atrial myxomaTrivial MR/ARNormal LV size and EF

Our PatientAPO secondary to large atrial myxoma

Transfer to CCU then CTSU for further Mx.

ProgressEmergency excision of atrial myxoma 6x5cm encapsulated LA tumour attached to inter-atrial septum.Causing obstruction & pul edemaBi-atrial exploration + excision of tumourExtubated on D1Post-op echo: EF 70% no PE

Day 0 Day 1 Day 2

Day 3 Day 4 Day 20Patient was discharge on D8 and SOPD FUOn Day 20Good Recovery, Class I II , ET 3-4 FOS

Atrial Myxoma

Background Most common 1 Heart tumour (40-50%)90% solitarty and pedunculatedMultiple tumours occur in 50% of familial case10% familial ( autosomal dominant)75-85% occur in LA ~25% RAAttach to fossa ovalisSymptomatic ~ 70g 140g

Myxoma- polypoid, round, oval in shapeSmooth / lobulated surfaceWhite/ yellow/ brownProduce numberus growth factors and cytokines e.g. interleukin-6

Histologylipidic cells embedded in a vascular myxoid stroma

In a series of 37 cases, 74% of tumors showed immunohistochemical expression of interleukin-6 while 17% had abnormal DNA content

EpidemiologyUS ~ 75 case / million autopsies75% sporadic Female Mean age 56 15% present as sudden death tumour embolism, HF, mechanical obstruction

History Asymptomatic (20%) symptomatic sudden death (15%)

Mechanical interference with cardiac fx embolization

LHF RHF systematic (L) Pulmonary (R)Exertional SOB fatigue infarct / haemorrhage PEOrthopnea peripheral edema of viscera Pul infarctionPND ascites e.g. CVA Pul HTPul edema visual lossPostural dizziness

Constitutional symptoms : fever, Wt loss, arthralgias, Raynaud ~ 50% of patient due to interleukin-6 overporduction

Physical JVPLoud S1 ( delay mitral valve closure)Early diastolic sound (Tumor plop) tumor hit against the endocardial wall Diastolic atrial rumble ( obstruction in MV)MR/ TR ( valvar damage/ prolapse)

DDXMitral RegurgitationMitral StenosisPul EmbolismPul HT , primary Tricuspid RegurgitationTricuspid Stenosis

IxLab: ESR, CRP, CBC, serum interleukin-6CXRECHO need to differentiate thrombus from myxoma Thrombus ( in posterior portion, in layers)Myxoma ( presence of stalk and mobility) MRI (point of attachment )CT scan

Treatment Medical treatment for CHF and arrhythmiaSurgical excision is the definitive txSafe and curativeRecurrence is possible if incomplete excision

Thank you

*ST HR 118 P pulmonalePoor R wave progression*