Ascites and jugular veins distension: look inside the heart

Case report.We report the case of a 82-year-old male patient, with a history of HCV-related cirrhosis and arterial hypertension, in good pharmacological control. He was admitted to the liver clinic because of fatigue, worsening ascites and peripheral oedema. Uptitrating diuretic regimen failed in reducing ascites. Furthermore, before startingbeta-blocker therapy for oesophageal varices, in order to exclude other comorbidities, the patient was referred to our cardiology unit for a cardiological assessment. Clinical examination and ECG were performed. At physical examination an unexpected jugular vein distension and a right side parasternal diastolic murmur were detected. These findings appeared not fully related with the plane hypothesis of worsening portal hypertension. The patient was submitted to transthoracic echocardiography (TTE): a huge (7.6 x 4.7 cm), echogenic, right atrial mass was identified; originating from the freewall, the mass filled the whole atrium, prolapsing through the tricuspid orifice during the entire cardiac cycle. Colour flow Doppler demonstrated flow aliasing along the mass suggesting obstruction, while tricuspid continuous wave flow gradient was not assessable. A dilated inferior vena cava (2.45 cm) with no inspiratory collapse was detected. These findings led to consider the mass as an unusually-rightsided atrial myxoma. The patient successfully underwent surgical excision. The histological analysis confirmed the echocardiographic suspect of myxoma. Discussion. This clinical case showed an uncommon giant, right atrium myxoma originating from the free wall. Patient’s symptoms were previously related to his hepatic condition, but a careful physical examination led to perform a TTE thus allowing to discover the real origin of the clinical signs. Myxomas are the most common type of primary cardiac tumor in all age groups. Less than 15% occur in the right atrium, usually originating from the interatrial septum, and grow to a significant size before producing symptoms resulting from mechanical interference with blood flow or from pulmonary embolization: an early diagnosis may bethen a challenge. In our case the myxoma grew to such a dimension to obstruct almost all the tricuspid inflow, its symptoms masked by the concomitant liver disease. Just a comprehensive clinical approach pointed out the right clue