Background Cardiac myxomas are the most common primary cardiac tumors. They are benign, but considered “functionally malignant” due to high potential for embolization. Transthoracic and Transesophageal echocardiography (TTE/TEE) are the imaging modalities of choice when evaluating for myxoma. Cardiac MRI, CT and PET scan are also useful in establishing a diagnosis. There are few documented cases of cardiac myxomas associated with Atrial Septal Defect (ASD) occluder devices. At present, there is no established relationship between myxoma and ASD occluder devices. Interestingly, cardiac myxomas have been theorized to predispose patients to Takotsubo Cardiomyopathy through CNS and systemic mechanisms.

Case Presentation A 75 year old female with a past medical history of hypertension, hyperlipidemia, atrial fibrillation, and an atrial septal defect with an ASD occluder device presented to an outside hospital with concerns for an acute cerebrovascular accident (CVA). Stroke workup revealed multiple embolic infarcts. Further evaluation with TTE revealed a normal ejection fraction and a semi-mobile mass in the left atrium, which appeared to be associated with the ASD closure device. During the hospitalization, the patient experienced another rapid decline, which was found to be a new embolic MCA infarct. Repeat TTE confirmed the pre-existing mobile mass and noted a hypokinetic apex with an ejection fraction of 20% concerning for Takotsubo cardiomyopathy. TEE visualized two left atrial mobile masses on the interatrial septum, and confirmed absence of a thrombus. Each mass appeared to be connected by a stalk, a finding highly suspicious of myxomas. MRI reported a well circumscribed, semi-mobile, spherical mass in the left atrium attached to the ASD occluder device and CT scan noted a large filling defect adjacent to the closure device. The patient was not a surgical candidate due to multiple comorbidities. She was kept comfortable and died shortly thereafter.

Discussion Thrombi are known to attach to ASD occluder devices. However, there are very few cases of cardiac myxomas doing so. A similar case report hypothesized that enhanced endothelialization after ASD occluder device placement may promote further cell transformation, leading to myxoma. Advanced imaging assists in further characterizing cardiac myxoma; However, there are still challenges in differentiating between myxoma and thrombus. In our case, TEE using real time 3D reconstruction provided the best visualization of the masses. Surgery is required to make a definitive diagnosis. Finally, myxomas may lower the threshold for development of Takotsubo cardiomyopathy, which can impact surgical planning.