The Patient Was…

The patient was a woman in her early thirties who suddenly began to experience periods of severe breathing difficulty at night.

She would wake from sleep gasping for breath and feeling extremely anxious. She was forced to sit up, which relieved her symptoms. She had no prior history of significant medical problems, no relevant family history, and was usually quite physically active. Se denied drug use and drank alcohol moderately in social situations.

Her general practitioner had examined her and found nothing of concern. He thought the problem might be anxiety and that the symptoms probably represented a sort of panic attack. He prescribed a tranquilizer to be taken at bedtime, but the woman was reluctant to follow that advice.

Her symptoms occurred only at night, were always the same when they occurred, but she also slept through many nights with no difficulty. The lack of regularity in their occurrence puzzled her and her physician.

Over a few months, she began to experience the difficulty in breathing more often, until it was waking her almost every night. When her physician again found nothing on examination, he referred her to me thinking she might be having some sort of cardiac problem, perhaps a disturbance of her heart rhythm. Disturbances of the heart’s regular rhythm, known as arrhythmias, can in fact be a cause for symptoms such as she was having.

When I saw her, she looked physically well but was very worried about her condition. Heart disease did not run in her family, and no family member had ever had what she was experiencing, now almost nightly. My general examination of her was unremarkable. There were no indications of any abnormalities that could be the cause of her symptoms, so I could really focus on her heart.

Since her symptoms occurred only at night, when she was sleeping, I asked her to lie on the examining table in the position she thought she normally slept in. She said she usually lay on her back when she first went to bed but realized that whenever she woke with shortness of breath she was lying on her left side. Her physician had examined her only when she was lying flat on her back.

I started my examination of her heart with her lying flat, and everything was normal. Her heart rhythm was regular and steady, and her heart sounds  —  those made by movements of the heart valves and flowing blood and heard with a stethoscope  —  were unremarkable. I then turned her onto her left side and heard a soft but unmistakable sound of turbulent blood flow, a so-called heart murmur.

These are many causes for heart murmurs and many different types and sources of murmurs. I was pretty sure that what I heard was a murmur due to some interference with blood flow through her mitral valve, the heart valve that controls blood flow from the left upper heart chamber (left atrium) to the left lower chamber (left ventricle). To confirm my finding, I re-examined her in different positions; only when she lay on her left side was the murmur audible. What was especially confusing, however, was that the murmur was sometimes not heard even when she lay on her side.

The question then was what could cause intermittent interference with blood flow through the mitral valve and occur only in a certain body position. The most likely cause was a cardiac myxoma, a rare, benign tumor inside the heart. Myxomas are usually attached to the inside of the heart by a stalk or stem that allows the body of the tumor to float around the heart chamber. In a certain body position the tumor can fall into the valve opening, blocking the flow of blood from the left atrium to the left ventricle. Blood would then back up from the atrium into the lungs creating buildup of fluid and causing shortness of breath. Changing body position would allow the tumor to move away from the valve and relieve the obstruction to blood flow.

Although myxoma tumors are usually benign, they are significant because they have to be removed by open heart surgery. Because their occurrence is rare  —  many cardiologists never see one in their entire career  —   and the treatment implications are so serious, I wanted to have another cardiologist examine her to confirm the diagnosis. I explained to her what I thought she had, and that I thought she should get a second opinion. She agreed, and I referred her to a senior consulting cardiologist whom I respected and whose clinical abilities I admired.

The consultant called me after seeing her and said he could not confirm my findings and did not believe she had a myxoma. He had no explanation for her symptoms, but did not think it was worth pursuing from a cardiology viewpoint. He never sent me a written report on his findings and opinion.

The patient returned to my office and reported what the consultant had said directly to her. Not only did he disagree with my conclusions, but he suggested that I was a young and relatively inexperienced cardiologist, and probably looking for exciting and unusual diagnoses. She was now in a quandary: What did she have and what should she do about it?

If this were today, the first step after examining her would be to obtain an echocardiogram, an ultrasound examination using sound waves to show the structures and function of the heart. Almost every cardiology patient nowadays undergoes an echocardiogram examination. It’s noninvasive, painless, easily obtained, and largely covered by insurance. It’s reported that over 7 million echocardiograms are performed in North America annually.

Echocardiography, however, was in its relative infancy when I saw this patient and had not yet become such a routine part of the evaluation of cardiac patients.. Nevertheless, it seemed imperative to visualize the interior structures of her heart, and so I sent her to the echocardiography department of the hospital. The test revealed clear and unmistakable evidence of the myxoma that I had diagnosed.

The patient underwent open heart surgery and the benign tumor was successfully removed. Her recovery was complete and uneventful and her symptoms were eliminated entirely.

Not to say “I told you so,” but rather to give what I felt was important follow up information to the consultant cardiologist who had seen her and doubted the presence of a myxoma, I went to see him and told him about the findings.

He looked directly at me, and said quite seriously, “You know, I thought she had a myxoma. We made a good diagnosis.”

He was a big man before. Was he now?