HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
A 53-year-old woman with no remarkable pathological history except for smoking 20 cigarettes/day. She attended the Emergency Department for aphasia and hypoaesthesia in the left arm that had appeared 12 hours earlier. On arrival she was haemodynamically stable. On physical examination she was in good general condition, conscious, cooperative and oriented, afebrile and eupneic. Hypoaesthesia in the right arm and aphasia. PCA: arrhythmic heart sounds, with holosystolic and panfocal diastolic murmur. Minimal crackles in both lung bases.

COMPLEMENTARY TESTS
The electrocardiogram showed a previously unknown atrial fibrillation with rapid ventricular response, although he recognised that he had felt palpitations for months.

Laboratory tests showed no significant alterations. A CT scan of the brain showed no ischaemic lesions at that time and she was finally admitted to the Neurology Department with a diagnosis of transient ischaemic attack dependent on the middle cerebral artery. She had a very satisfactory evolution with a control CT scan showing a small ischaemic spot in the right parietal area, suggesting a cardioembolic cause. Since the risk of haemorrhagic transformation was low, it was decided to start anticoagulant treatment with acenocoumarol. As part of the cardioembolic source study, echocardiography was performed. The study was performed in AF with very rapid ventricular response, showing the difficulty to control the rate with beta-blocker therapy. A large mass (99 mm x 71 mm) dilating the left atrium was observed. The mass had heterogeneous echogenicity, multiple lobes and a 36 mm wide implantation pedicle. One of its lobes was interposed between the leaflets of the mitral valve, generating severe insufficiency and obstruction (with a high mean gradient 12 mmHg) and a concomitant severe insufficiency justifying the difference between mean and peak gradient 20 mmHg. In addition, he had moderate tricuspid regurgitation and severely depressed left ventricular ejection fraction (EF 30 % by Simpson).

EVOLUTION
With this information the patient was presented for cardiac surgery, the most likely diagnosis being myxoma. No previous clinical manifestations classically associated with myxomas, such as weight loss or fever, were found. She only presented progressive dyspnoea, which we attributed mainly to the double mitral lesion caused by the myxoma. The myxoma was removed from the left atrium without complications. The mitral and tricuspid valves were not damaged, so mitral and tricuspid anuplasty was performed to solve the severe insufficiencies described. Pathological analysis of the atrial mass revealed a myxoma measuring 9 × 7 × 4 cm with patches of calcification and thrombi on its surface.

DIAGNOSIS
Giant atrial myxoma with embolic phenomenon. Severe mitral stenosis and mitral insufficiency secondary to myxoma. Ischaemic stroke with involvement of the right MCA territory.
