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Aug 1998 -J. T. @worldnet.att.net
I am a 54 year old school librarian in good health.
On May 1,1997, I had an atrial myxoma removed. I was told that it had been the size of a small pear and had involved the right and left atria. The convalescence was complicated by an inability to tolerate digoxin and I had to return to the hospital for an additional week to regulate medication. I have been told the the nature of the surgery impaired my heart and that atrial fibrillation will continue. (There was a possibility that the heart rate would become normal, but this is not to be).
I had numerous atrial fibrillation episodes following the surgery, that last, and most worrisome, was 5/12/98 that lasted a week and caused me to miss work. Sotolol failed. In May,1998 I went into atrial fibrillation that lasted for a week. 4 verapamil a day finally slowed the heart beat and now I am on Rythmol and Aspirin.
Yes, use my question on the journal.
Thanks, J.T.
reply
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Cardiac tumors are rare, and of these atrial myxomas are the most common. Most of the patients with this condition are over 50 years of age and are women.There is a right atrium (blue) returning blood from the body to the right side of the heart and then to the lungs (to be oxygenated), and a left atrium that feeds the left side of the heart with the oxygenated blood from the lungs. Atrial myxomas are most often found on the left side of the heart and are attached to the septum that divides the atria. |
Atrial myxomas vary in size and can grow to several centimeters in diameter.
See the case report of a 47 year old computer technician with a one year history of painful skin lesions on his palms and soles. Each episode lasted 1-2 weeks. The patient had embolic events which included episodes to both feet and to the right arm. The patient had shortness of breath bending forward or sitting up, which resolved when lying back. (This report shows an echocardiogram as well as an angiogram showing the myxoma in motion)
Atrial myxomas are rare, but clinicians ( e.g. Fisher , Cardiovasc. Rev. Rep. 9:1195, 1983. ) have reported the signs of a myxoma can include: shortness of breath, weight loss, fever, coughing up blood, passing out, sudden death (rare), stroke, heart attack, and atrial fibrillation.
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Some of these symptoms are not unexpected as the myxoma is a soft mass that is mobile and which can block the mitral valve or release release emboli into the blood stream. These emboli can block vital arteries and cause damage(strokes occur with blockages in the brain, heart attacks with blockages in the arteries going to the heart) |
Most of the myxomas occur on the left side of the intra-atrial septum and the treatment is the removal of the myxoma and usually part of the septum. The removal of tissue around the origin of the myxoma is felt to be important to prevent the recurrence of the tumor, and in most cases the recurrence rate is less than 2%. This being said, cardiac surgery in general and surgery which involves the atrial septum (including operations the repair holes in the septum) are associated with atrial fibrillation (see a representative electrocardiogram) and atrial flutter. Often this resolves over the months following the operation. An important question is where or not one should anticoagulate a postoperative patient with an agent such as warfarin as opposed to giving Aspirin.
In general there have been five randomized clinical trials compared warfarin with no medication for the prevention of strokes in atrial fibrillation patients in general. They were:
The average combined risk reduction with warfarin for all five studies was 68% (95% C.I. 50% to 79%). Three trials compared aspirin and warfarin:
and found that warfarin was more effective in preventing strokes. The combined risk reduction for the combined three studies comparing warfarin to aspirin was 47% .
The choice of Warfarin verses Aspirin depends on whether the doctor feels the patient is in a high or low risk group for an embolism.
Therapies that control, terminate and prevent atrial fibrillation or flutter include medications and electrical treatments including external cardioversion (see Recording of a series of shocks for Atrial Flutter), atrial pacing (see representative EKG of atrial pacing) or implantation of an atrial defibrillator. Rhythmol is an effective medication and is a class I anti-arrhythmic. This class includes other medications such as Tambacor, Procan, Quinidine and Norpace. Most Class I anti-arrhythmic work better with a beta-blocker, which in addition may prevent fast conduction of atrial flutter to the ventricle. Rapidly conductin atrial flutter can resulting in heart rates faster than 270/min (see recording of fast conduction to the ventricle).
Sotalol is a class III anti-arrhythmic with about the same efficacy as Rythmol, the problem with Sotalol is that the medication can cause a life threatening arrhythmia (see recording of Torsde de Pointes with Sotalol) especially with high doses, in the presents of a low serum potassium or renal failure.
Verapamil is a class IV anti-arrhythmic but has a dual effect in atrial fibrillation. Theoretically it should increase the chance of atrial fibrillation as it decreases the refractory period of the atrium, and secondly it slows the conduction of the fibrillation to the bottom of the heart. This slowing of the heart rate is the best role for Verapmil. This approach of slowing and not converting the atrial fibrillation may be a reasonable choice as it makes the paitent less symptomatic and does not carry with it major side effects such as sudden death. The same can be said for digoxin and most beta-blockers other than Sotalol. It is also important to realize that although at first a patient may feel unwell with atrial fibrillation, most adjust and function well with a drop of only 20% in their exercise capacity.
In the end, no anti-arrhythmic has been shown to prevent blood clots associated with atrial fibrillation. Further post-operative atrial fibrillation often does not recur and long term anti-arrhythmics may not be required.
Long term one expects patient who have had a successful operation to do well but remember:
