1. CASE PRESENTATION RA MYXOMA Presenter: Dr. Hriday Ranjan Roy Consultant, Surgery Rangpur Medical College Hospital

2. THE EVER LARGEST RIGHT ATRIAL MYXOMA IN NICVD RA MYXOMA 3. Mr. Jalal Ahmed- 45 years, a cultivator, hailing from Coxs Bazar admitted into NICVD on 21/11/2006 with the complaints of-1) Intermittent Syncopal attack for 1 month 2) Dyspnoea for 11/2 months 3) Constitutional symptoms for 2 months 4. The presenting complaints was first noticed by him 2 months back with low grade fever- which was irregular and was not associated with cough or hemoptysis. He also developed headache, malaise and some sorts of neurological dysfunction. For the last 11/2 months, he developed dysponoea- mostly while he lie on bed, but did not relieve by sitting upright. It also occasionally aggravated by exertion. He has no H/O of asthma or tuberculosis. 5. During last 1 month, he began to have Syncopal attack 2/3 times a day. Very occasionally, it was associated with convulsion, palpitation and tightness of chest. He has no H/O DM, HTN or smoking. For these above complaints, he was admitted into Cittagong Medical College Hospital on 5/11/2006 and was treated by anti-epileptic drugs (Discharge Certificate contains no information). But as the symptoms did not improve, he was referred to DMCH on 14/11/2006. 6. The diagnostic work out done in DMCH were1) CBC- Hb-13.6 gm%, ESR-58, TC-11,500 DC- N-90%, L-8%. 2) RBS- 4 mmol/L 3) SGPT- 25 U/L 4) S. Billirubin- 1.16 mg% 5) S. Creatinine- 1.64 mg% 6) CXR- normal 7) ICT for malaria- negative 8) CT scan of brain- normal 7. With the above scenario, he was empirically diagnosed as a case of cerebral malaria and was treated as such ( Inj- Jasoquine). But as the symptoms did not improve, an echo was done and was diagnosed as a case of RA myxoma and was referred to NICVD on 21/11/2006. 8. General examination on admission (in NICVD)Appearance- ill looking, confused. P- 100/min B.P- 100/70 mmHg Neck veins- engorged Heart- Diastolic murmur at tricuspid area, localized. Lung- clear No jaundice, edema, enlarged L. nodes or clubbing. P/A- normal. 9. Reevaluation was done in Cardiology Unit-I on 23/11/2006 as followsCXR 10. ECG 11. Echo ( Done by Dr. Mazhar-AP)AP4CH, 2D 12. Other baseline investigations was within normal limits He was then submitted urgently to SU-III for emergency surgery. On 25/11/2006, Under G/A with CPB, open heart surgery was performed. ECCT was 96 min, XCT- 52 min. 13. Per-operative findings and procedures wereA huge ( 9cm 7cm) encapsulated mass, occupying 2/3rd in RA and 1/3rd in RV and was protruding into RVOT (as in Echo). It was attached to the limbus of fossa ovalis by a narrow stalk. Careful removal of the mass was done to avoid pulmonary embolism. 14. Stages of Operation (Bypass established, RA- dilated) 15. The mass is being delivered after RAtomy 16. The mass is being separated 17. RA cavity after removal of the mass 18. Video Show of the surgeryPer Op Video.3gp 19. Photographs of the Mass after removal 20. Mass ( Cont) 21. Mass ( Cont) 22. Regurgitant test was done. TV regurgitation G-IV, 23. The annulus of the TV was found to be dilated with TR G-IV De Vega annuloplasty was done by 3/0 plolene. 24. De Vega (Cont.) 25. Post operative periodExtubation was done on 26/11/2006 morning with smooth ICU outcome. Some sorts of inotropic support was needed( Dopa, Dobuta) for 2/3 days. 26. Histopathology Report Consistent with myxoma 27. Histopathology Report (Cont..) 28. Histopathology Report (Cont..) 29. Post operative echo 30. Post operative echo cont.Normal LV function Mild septal hypokinesia Tricuspid regurgitation Grade-II 31. Post operative pulmonary functionHeight- 170cm, Weight- 50 Kg Variables VC (L) FVC (L) FEV1 (L) FEV1(%) PEF (L/s) MVV (L/m)Measured 4.01 3.59 3.37 93.87 9.72 59.9Predicted 4.23 4.23 3.48 82.55 8.41 148.8% Predicted 94.8 84.9 96.8 113.71 115.6 40.3Comment- Normal pulmonary function 32. Personnel involved in treatment: Cardiology Unit-IProf. A. A. Shafi Majumder and his team. Surgery Unit-IIIProf. M. Abul Quashem and his team. 33. The final situation of the patient Every parameters are good. Neurological symptoms has been disappeared. He is feeling well. 34. He is smilingThe gentlemans smile is valued trillion dollars to us. 35. THANK YOU ALL