cardiac myxoma represents approximately 50% of all benign cardiac tumors in adults , with left atrial myxomas constituting 75% of all myxomas . usually , myxoma is a solitary mass .
multicentric cardiac myxomas are very rare and usually , biatrial . the incidence is < 2.5% of all cardiac myxomas .
familial multicentric cardiac myxomas may present as a case of left atrial ( la ) and left ventricular ( lv ) mass simultaneously .
we report a 26-year - old female patient who presented to our emergency department with acute onset of dyspnea and was diagnosed as multicentric right atrium ( ra ) and right ventricle ( rv ) myxoma with embolization of tumor fragments to the pulmonary artery ( pa ) during evaluation with transthoracic echocardiogram and high - resolution computed tomography ( hrct ) of the thorax .
a 26-year - old female presented to the emergency department with sudden onset of dyspnea and left precordial pain of 6 hr duration .
she had no history of exertional dyspnea , fever , weight loss , prolonged immobilization , syncope , focal neurological deficits , substance abuse , endocrine disorders and dermatological ailments in the past .
the patient 's physical examination revealed blood pressure of 94/60 mmhg , heart rate of 120 beats / min , respiratory rate of 40/min , elevated jugular venous pressure with prominent  v wave . on cardiovascular system examination , s1 was normal , s2 was narrowly split with loud p2 ; a pan - systolic murmur of grade iii / vi intensity was present along left sternal border .
pulse oximetry revealed a saturation of 85% at room air increasing to 90% with 100% oxygen at 6 l / min .
laboratory examination revealed hemoglobin - 12.6 g / dl , total leukocytes count - 12.600/l and platelet count of 1,00,000/l .
transthoracic echocardiogram showed a large pedunculated mobile mass in ra with heterogenous echotexture attached to ra free wall and another mass attached to interatrial septum near fossa ovalis [ figure 1a ] .
another mass was seen in rv measuring 11 mm  11 mm just beneath the septal leaflet of tricuspid valve [ figure 1b ] .
larger ra mass was prolapsing into rv producing severe eccentric tr jet with a gradient of 60 mmhg [ figure 1c , supplementary movie 1 ] .
inferior vena cava was free of any mass or thrombus ( supplementary movie 2 ) .
hrct thorax revealed embolization to the lateral aspect of right pa and along the medial aspect of left pa causing subtotal obstruction with pulmonary infarct in left lung [ figure 2a and b ] .
( a ) modified apical 4 chamber view tte showing a 2.4 cm  2.4 cm pedunculated myxoma in the right atrium ( ra ) attached to ra free wall extending to interatrial septum , ( b ) modified apical 4 chamber view tte showing 1.1 cm  1.1 cm pedunculated myxoma attached to the septal leaflet of the tricuspid valve , ( c ) cw doppler across the tricuspid valve showing severe high - pressure tr with 60 mmhg gradient , ( d ) tte basal short axis view showing dilated rvot , pulmonary artery and heterogenous pedunculated right atrium mass with calcium specks attached to ra free wall ( a ) high - resolution computed tomography of the thorax showing embolic fragment in the lateral aspect of right pulmonary artery ( pa ) and medial aspect of left pa , ( b ) high - resolution computed tomography thorax showing pulmonary infarct in left lung field once the diagnosis of multicentric ra and rv myxoma with tumor fragment embolization to pa was made , emergency surgery was performed by standard median sternotomy and cardio - pulmonary bypass using bicaval and ascending aortic cannulation to prevent further embolic events .
the ra was then opened and a round lobulated mass measuring 3 cm  2.5 cm  2.5 cm was found attached to the ra free wall by a pedicle . another mass attached to interatrial septum near fossa ovalis was excised .
multiple degenerating tumor strands were detected in ra , which were not visualized by transthoracic echocardiography .
another solitary mass was excised from the rv originating beneath the septal leaflet of tricuspid valve [ figure 3a and b ] .
after the direct closure of ra , patient was weaned off the extra - corporeal circulation .
( a ) intra - operative findings showing 3 right atrial myxomas one of which the largest one attached to right atrial free wall , ( b ) gross morphology of excised myxoma : pedunculated lobulated mass held by forcep and degenerating myxomatous mass with hemorrhage seen on extreme left side of picture , ( c ) photomicrograph ( h and e , 100 ) loose myxomatoid stroma with stellate and spindle cells ( from right atrium mass ) , ( d ) photomicrograph ( h and e , 45 ) myxoid stroma with scanty stellate cells and spindle cells amidst degenerating cells and hemorrhage ( from right ventricle mass ) gross pathological examination revealed multiple flesh - colored soft to firm lobulated mass . gross foci of degeneration were detected .
microscopy revealed hypocellular tumor tissue with myxoid background , isolated spindle and stellate cells with no abnormal mitosis or pleomorphism [ figure 3c and d ] . gross pathology and histopathological examination were consistent with the diagnosis of cardiac myxoma .
after the surgical excision of the tumor , severity of tr decreased from severe to mild .
we experienced a case of 26-year - old female with acute pulmonary embolism attributed to embolization of degenerating tumor fragments from multicentric ra and rv myxoma , sporadic in nature , as there was no family history of cardiac tumors in first - degree and second - degree relatives .
our patient had no constitutional symptoms of fever , weight loss , malaise or joint pains .
pulmonary embolism is the most dreaded and devastating complication of right - sided myxoma . in cases of right atrial myxomas ,
nevertheless , there have been reports of embolization of thrombi or tumor fragments into the pulmonary vessels in cases of right atrial or right ventricular myxoma .
carney 's syndrome consists of myxomas in other locations ( breast or skin ) , spotty pigmentation ( lentigines , pigmented nevi or both ) and endocrine overactivity ( pituitary adenoma , primary pigmented nodular adrenocortical disease , bilateral testicular tumors and schwannomas .
familial myxomas tend to occur in younger individuals , are often multiple in locations and more likely to have postoperative recurrences . in the case
presented here , despite being a multicentric tumor with younger age at presentation , there was no family history unlike other multicentric cardiac myxomas and thus favoring a sporadic occurrence .
. early surgical excision of the cardiac myxoma is advocated to prevent embolization , sudden cardiac death and for relief of obstructive symptoms .
cardiac myxomas recur in approximately 1222% of familial cases and in < 3% of sporadic cases .
recurrence is attributed to incomplete , inadequate resection of the tumor , multicentricity , younger age at diagnosis and familial myxoma syndrome .
annual follow - up examination with echocardiography is recommended in multicentric myxoma postoperatively due to recurrence risk .
in patients presenting with sudden onset of dyspnea especially young patients , tumor embolization from right sided tumors should be kept in the differential diagnosis , and timely transthoracic echocardiogram in the emergency room can help in fast - tracking the patient for urgent cardiac surgery to prevent the catastrophic complication of pulmonary embolism and sudden cardiac death .
 multicentric cardiac myxoma is a rare syndrome ; usually it is familial . 
 we report a rare case of sporadic right atrium ( ra ) and right ventricle ( rv ) myxoma in a 26-year - old female presenting to our hospital for the evaluation of sudden onset of dyspnea and left precordial pain attributed to the embolization of degenerating tumor fragments to the pulmonary artery ( pa ) . 
 the exact incidence of sporadic multicentric ra and rv myxoma presenting as acute pulmonary embolism is unknown as multicentric ra and rv myxoma are very rare . 
 myxomas presenting as pulmonary embolism is < 10% . 
 majority of cardiac myxomas present as exertional dyspnea , chest pain , positional syncope , fever , weight loss and other constitutional symptoms . 
 any young patient presenting with acute onset dyspnea with multiple cardiac masses may have tumor embolization to the pa diagnosis with transthoracic echocardiography and high - resolution computed tomography of thorax , fast - tracks patient transfer for urgent cardiac surgery to prevent further embolization . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION