1. Case presentation Wael Tantawy, MD Cardiologist KFMMC wktantawy@gmail.com23 may 2013

2. history 67 y old saudi female. K/C of HTN, AF on warfarin C/O Presented in her regular F/U with the primary care clinic complaining of SOB & LL edema. Referred to cardiology clinic & echocardiography was requested.

20. Differential Diagnosis LA mass most probably LA myxoma. (abnormal attachment) LA thrombus. (abnormal place) Lipoma. Liomyosarcoma. Metastasis from the lung.

21. What is the next step? 2- Further investigation. 1- Course of anticoagulation.

22. 3- Call the surgeon

23. Does the PFO change the decision?

24. Continue oral anticoagulation. F/U echo after 2 weeks.  The patient came back after 2 week.  She was compliant to her ttt with INR 2.3.  TTE was done for F/U

32. What are the possibilities ? Liomyosarcoma. Bleeding inside myxoma. Metastatics 2ndry to lung Tr Enlarged thrombus

33. What is the next step? 1- Continue anticoagulation. 2- Further investigation.

34. 3-Call the surgeon.

35. The increase in mass size despite adequate dose of anticoagulation increase the suspicion of TUMER. Due to the site of the mass & its encroachment on the Rt upper PV orifices. We elected to do further investigation. CT Scan chest. TEE also done for better visualization of the mass attachment

37. CT chest

40. TEE

49. What is the site of attachment of such mass?

54. What is the next step? 1- Continue anticoagulation. 2- Further investigation. 3- Call the surgeon.