An unusual right atrial myxoma triggering presumed takotsubo syndrome in a 97-year-old female

A 97-year-old female was admitted to the emergency department of our hospital due to paroxysmal nocturnal dyspnea and chest pain. At the hospital admission, the patient manifested transient psychomotor agitation and dysarthria. On physical examination, blood pressure was 115/60 mmHg and pulse 96 b.p.m. On blood tests, troponine I was 0.08 ng/mL (normal range <0.04 ng/mL). Electrocardiography (ECG) showed sinus rhythm and ST segment elevation in both inferior and anterior leads except in lead V1. Transthoracic echocardiography (TTE) revealed a right atrial multilobulated, hypermobile, echogenic cauliflower mass (maximum size of 5 cm × 4 cm), which was attached to the tricuspid lateral annulus with a short stalk (Figure 1A). The right atrial mass, which had filiform extremities and was found to prolapse through the tricuspid valve into the right ventricle, was ascribed to a peduncolated myxoma. Its motion was very rapid and uncoordinated, with increased peak antegrade velocity (V_max = 35 cm/s), as precisely measured by pulsed wave tissue Doppler imaging (PW-TDI) (Figure 1B). Estimated left ventricular ejection fraction (LVEF) was normal (60%), and no significant valvulopathy was detected. Finally, a bulging of the interatrial septum with right-to-left shunt, through a patent foramen ovale (PFO), was observed by using colour Doppler (Figure 1C). Acute ischaemic lesions were excluded by brain computed tomography scan.