case_images: PMC10897023_01
case_images: ECGs sequence. (A) Admission ECG: Sinus rhythm/HR 65 rpm/PR 140 ms/QRS axis +30 /QRS, 80 ms/QT 320 ms/ST segment elevation in DI, DII, DIII, AVF, V5, V6. (B) Day 2 ECG: Sinus rhythm/HR 70 rpm/PR 160 ms/QRS axis +30 /QRS 80 ms/QT 420 ms/negative T waves in DI, DII, aVL, aVF, V4, V5, V6/biphasic T wave V3. (C) Day 6 ECG: Sinus rhythm/HR 65 rpm/PR 140 ms/QRS axis +60 /QRS 80 ms/QT 400 ms/normalization of the ST segment and T waves.
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case_images: PMC10897023_01_fcvm-11-1323492-g001.jpg
case_images: F1
case_images: The admission electrocardiogram (ECG) showed sinus rhythm associated with ST-segment elevation in leads I, II, III, aVF, V5, V6 (Figure 1A).
case_images: Coronary angiography and ventriculography. (A) Angiographically normal right and left coronary arteries. (B) Left ventriculography in diastole, compared to systole (C), where an apical balloon is observed (white arrows).
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case_images: PMC10897023_01_fcvm-11-1323492-g002.jpg
case_images: F2
case_images: Coronary angiography revealed coronary arteries without atherosclerotic lesions (Figure 2A and Supplementary Movie S1-S5) and left ventriculography exhibited apical ballooning (Figures 2B,C and Supplementary Movie S6).
case_images: Transthoracic echocardiography. (A) TTE, apical 4-chamber view. Dilation of the ventricular cavity is seen at the apical level in systole (white arrows), and a mass is evident in the left atrium implanted in the interatrial septum. (B) TTE, apical 3-chamber view. Mass in the left atrium with a maximum diameter of 51 mm. (C) Polar map of the left ventricular strain. Illustration of apical-medial involvement and basal preservation.
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case_images: PMC10897023_01_fcvm-11-1323492-g003.jpg
case_images: F3
case_images: Transthoracic echocardiography (TTE) was performed, highlighting a characteristic contractile pattern: hypokinesia/akinesia of the apical-medial segments and hyperkinesis of the basal segments, which resulted in LV systolic dysfunction (LVEF 48%, LVEDVi 61.25 ml/m2) (Figure 3A and Supplementary Movie S7, S8) and type II diastolic dysfunction [with elevated filling pressures (E/e' ratio 18) and left atrium dilatation (35 ml/m2)]. Furthermore, incidentally, a mobile, pedunculated, 51 x 18 mm long mass was found in the left atrium, adhered to the interatrial septum (Figure 3B). Finally, the strain analysis of the left ventricle confirmed the severe compromise of myocardial function at the apical-medial levels (Figure 3C).
case_images: Cardiac computed tomography/3D-tools. (A) Cardiac contrast enhanced computed tomography horizontal long axis (4 - chambers) shows a lobulated, frond-like left atrial mass with villous borders (high risk of embolism), diameters of 39 x 39 x 20 mm, heterogeneous, isodense with punctate hypodense areas (clots), arising from the upper interatrial septum. (B) Oblique reformat volumen rendered 3D cardiac tomography demonstrated shows realistic anatomical relationships of left atrial mass near the ostium of the right inferior pulmonary vein. (C) Three-dimensional intracardiac navigation of 360 degrees revealed the dependence of the interatrial septum and the relationship with pulmonary veins of atrial mass.
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case_images: F4
case_images: The cardiac computed tomography (CT) and its 3D tools better characterized the intracavitary mass, showing a bilobed, villous, 39 x 39 x 20 mm long tumor of low attenuation, and additionally demonstrated uninvolved pulmonary veins (Figures 4A-C and Supplementary Movie S9-S11).
case_images: Anatomical piece and histology of the atrial mass. (A) Ovoid, reddish tumor, with a hairy surface, friable to the touch, approximately 4.0 cm2 x 3.9 cm2 in length. (B) Histology, stellate cells without atypia, immersed in vascularized myxoid tissue. HIM 4x. (C) Cells positive for calretinin staining, 10x.
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case_images: PMC10897023_01_fcvm-11-1323492-g005.jpg
case_images: F5
case_images: The cardiac computed tomography (CT) and its 3D tools better characterized the intracavitary mass, showing a bilobed, villous, 39 x 39 x 20 mm long tumor of low attenuation, and additionally demonstrated uninvolved pulmonary veins (Figures 4A-C and Supplementary Movie S9-S11).