Hrev_master Question Given the patient’s history and POCUS results, what is the most likely diagnosis? 1. Endocarditis 2. Atrial myxoma 3. Cardiac lymphoma 4. Atrial thrombus Emergency Care Journal 2024; volume 20:11717 [Emergency Care Journal 2024; 20:11717] [page 1] What does a floating mass in a young patient's heart do? Tommaso Sonnessa, Daniela Vaira Vita-Salute San Raffaele University and Emergency Department, San Raffaele IRCCS Hospital, Milan, Italy Correspondence: Tommaso Sonnessa, Vita-Salute San Raffaele University and Emergency Department, San Raffaele IRCCS Hospital, Milan, Italy. E-mail: Sonnessa.Tommaso@hsr.it Key words: atrial myxoma; cardiac myxoma; cardiac tumor; echocar- diography; chest pain. Contributions: both authors cared for the patient, collected details of the case, drafted the manuscript, approved the final version, and stated the integrity of the whole work. Conflict of interest: the authors declare no potential conflict of interest. Availability of data and materials: all data underlying the findings are fully available upon reasonable request to the corresponding author. Ethics approval and consent to participate: as this was a descriptive case report and data was collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guide- lines. Informed consent: the patient provided consent for access to medical records at the time of admission. Received: 3 September 2023. Accepted: 19 October 2023. Early view: 31 October 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:11717 doi:10.4081/ecj.2023.11717 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. A previously healthy 57-year-old male patient presented to our emergency department for palpitations, dry cough, and non- exertional chest pain. He denied lipothymia or syncope. Blood pressure was 160/90 mmHg, heart rate 76 beats/min, body tem- perature 36.4°C, respiratory rate was 14 breaths/min, and oxy- gen saturation 96% on room air. Physical examination revealed symmetrical air entry without wheezing or crackles, and a classi- cal diastolic "tumor plop", not accompanied by another signifi- cant murmur at cardiac auscultation. Laboratory tests were all in the normal range, including troponin T (9.1 ng/mL, normal value <14) and C-reactive protein (2.2 mg/dL, normal value <6). An electrocardiogram showed a sinus rhythm and normal ven- tricular repolarization. Point-of-care ultrasound (POCUS) revealed a floating mass within the left atrium and a normal lung pattern without pleural effusion. Non -co mmerc ial us e o nly Images in Emergency Answer An urgent transthoracic echocardiogram was performed and confirmed the primary diagnosis: a floating mass with a maximum diameter of 20×48 mm within the left atrium, originating from the base of the inter-atrial septum (IAS) and involving the hinge point of the anterior mitral flap. In the diastolic phase, the mass engaged the mitral valvular plane and prolapsed across the mitral valve ori- fice, resulting in a moderate functional stenosis (Gmed 6 mmHg) and a moderate-to-severe mitral valve insufficiency, a slight peri- cardial effusion, and a normal ejection fraction (67%) (Figure 1 and 2). A diagnosis of atrial myxoma was made and the patient was hospitalized in the Cardiovascular Surgery Unit. A chest X-ray and coronary angiography were performed and the results were nor- mal. The patient was then scheduled for surgery. The operation was performed through a left atriotomy. The tumor appeared as a pale pink, grape-like, semi-transparent mass. Histological analysis con- firmed that the lesion was consistent with atrial myxoma, extend- ing to the implant base on the IAS, between the outlet of the left auricle and the mitral anulus. The clinical post-operative period was uneventful, and the patient was dismissed on the 4th postoper- ative day. Cardiac myxoma may cause cardiac obstructive symp- toms, systemic embolism, and cerebral infarcts.1,2 Timely diagno- sis and treatment are essential for the prevention of life-threatening complications.3 Transthoracic echocardiography is a readily avail- able, portable, low-cost imaging modality, which gives the first clue as to the etiology of a cardiac mass.4,5 Transesophageal imag- ing, however, has been shown to be superior to study for more detailed evaluation and characterization of cardiac masses.5-7 Characteristics of a mass such as location, mobility, attachment, and appearance can help determine whether a mass is benign or malignant.8 Cardiac myxoma needs surgical excision often on an emergency basis. Data published over the past decades show excellent overall outcomes in operative mortality, short- and long- term survival, and tumor recurrence.3 References 1. Lee SJ, Kim JH, Na CY, Oh SS. Eleven years’ experience with Korean cardiac myxoma patients: focus on embolic complica- tions. Cerebrovascular Dis (Basel, Switzerland) 2012;33:471-9. 2. Jawaid A, Naqvi SY, Wiener R. Atrial myxoma presenting as acute ischaemic stroke and chronic right lower leg claudication. BMJ Case Rep 2018;11:e227427. 3. Islam AKMM. Cardiac myxomas: a narrative review. World J Cardiol 2022;14:206-19. 4. DePace NL, Soulen RL, Kotler MN, Mintz GS: Two-dimensional echocardiographic detection of intraatrial masses. Am J Cardiol 1981;48:954-60. 5. Pyke FE. Seward JB, Edwards WD, et al. Primary cardiac tumors: Experience with 30 consecutive patients since the introduction of two-dimensional echocardiography. J Am Coll Curdiol 1985;5: 1465-73. 6. Seward JB, Khandheria BK, Oh JK, et al. Transesophageal echocardiography: Technique, anatomic correlations, implemen- tation. and clinical applications. Mayo Clin Proc 1988;63:649-80. 7. Salmon K, Decoodt P, Capon A. Detection of a left atrial myxoma by systematic transesophaeal echocardiography in stroke. Am Htwt J 1991;122:580-3. 8. Mankad R, Herrmann J. Cardiac tumors: echo assessment. Echo Res Pract 2016;3:R65-R77. Figure 1. Atrial myxoma in apical four-chamber view on transthoracic echocardiography. Figure 2. Atrial myxoma in apical four-chamber view on transthoracic echocardiography (upper panel) Color Doppler on mitral valve (lower panel). [page 2] [Emergency Care Journal 2024; 20:11717] Non -co mmerc ial us e o nly