A Mysterious Fall Was the First Sign Something Was Wrong
What felt like a shove brought her to her knees. It wasn't until a year later that an ultrasound revealed the cause — and rushed her into surgery.
By Lisa Sanders, M.D.
"OK, let's go," the hairdresser cheerfully instructed the 67-year-old woman reclining at the hair-washing basin. The woman rose, her hair swathed in a fluffy towel, but at the first step she stumbled. She smiled, a little embarrassed, and looked behind her. Did someone bump into her? As she reached the doorway to the room of mirrors and styling chairs, the woman again felt a shove. This time it sent her up against the doorway, and she dropped to her knees. The hairdresser grabbed her arm and steadied her. "You OK?" she asked, helping the woman to her feet. "I guess so," the older woman answered. But she hadn't been, for those two brief moments.
On the drive back to her home near Pittsburgh, the woman worried about what happened. She’d never felt anything like that before. Weeks later, at her annual physical, she tried to describe the experience to her primary-care doctor, Rajiv Jana. He wasn't sure what to make of it either. But he didn't seem worried once he understood that it hadn't happened since then. "Do you think I had a stroke?" she queried insistently. He asked again: "You felt completely fine afterward? No weakness anywhere?" "Completely fine," she replied. "I still feel fine. I work in my garden and ride my bike every day. Nothing has changed." "Then I don't think it was a stroke," Jana reassured her. "Let me know if it happens again."
It didn't happen again, and eventually she stopped worrying. She didn't go back to Jana's office for another year, and when she did, it was for an infection in her leg that she got while gardening. She had taken antibiotics, and it was healing well. "Anything else?" the doctor asked after examining her leg. There was one other thing: She had a pain in her left side. She wasn't sure what it was, but it didn't feel like strained muscle. It started a few months earlier. Did he think she needed an X-ray?
Jana shook his head. "I don't think an X-ray would tell us anything. Let's get an ultrasound instead," he suggested.
Two days later, the woman was lying on an exam table, her bare abdomen slick with the clear, cool gel the ultrasonographer spread to help the probe see through the skin into her belly and chest. She’d had an ultrasound before, and this seemed to be taking a really long time. Finally she had to ask: Did the technician see anything abnormal? The woman wielding the probe shook her head; the radiologist would have to read the scan. But, she added, the patient should check her chart when she got home. The whole encounter seemed strange and a little disturbing.
The patient was still on the road when her phone rang. "Are you at home?" the familiar voice of Rajiv Jana asked. "I’m still driving, but tell me anyway," she said a little impatiently. What did the scan show? Silence filled the car. Finally he said, "The scan shows that there might be something inside your heart," a mass in one of the heart's chambers. Maybe it was a blood clot. Maybe it was a tumor. In either case, she needed a cardiologist and a CT scan. He’d let her know when the test was scheduled.
The unsettling news was still visible on her face at a funeral she attended that weekend. A friend, Sandi, immediately saw that something was wrong. "I think I need a cardiologist," the worried woman told her. She briefly explained what her doctor had said. Sandi knew a great cardiologist, she told her friend: Dr. Ricci Minella. He saved her husband's life after his heart attack. Thank you, the woman replied gratefully. I will call him on Monday.
It was a call she didn't have to make. That evening just before dinner, her cellphone rang. It was Minella. He introduced himself and got right to the point. That mass in your heart needs to be evaluated, he said. It could be a serious problem. Come to the University of Pittsburgh Medical Center Shadyside first thing Monday morning — 7 a.m. — and we will figure it out.
Her husband drove her to the medical center in Pittsburgh's East End. Minella met them in the cardiology suite. He was a middle-aged man with an air of easy confidence. He had already reviewed her ultrasound, and he was concerned. Her primary-care doctor was right — they did need a better look at the mass — but rather than a CT scan, he wanted to get an ultrasound from inside her chest. In the procedure room, Minella held up a metal instrument attached to a long, slender rubber tube. At the far end, Minella showed her, was an ultrasound probe. He explained that he wanted to place the probe in her mouth and down her esophagus, which runs next to the heart. He’d be able to get a good look at the mass that way. He gave her some sedating medicine and narrated what he saw to her worried husband. There was a mass. It looked to be about the size of a golf ball and was tethered to the right side of the heart by a narrow stalk. It looked like a benign tumor, called a myxoma, Minella said. It was not a cancer, but it still had to come out.
Myxomas are rare. In autopsy studies, around 100 myxomas are seen per one million population. For reasons that are not well understood, they are more common in women than in men. Size at the time of diagnosis can be variable. Most are ovoid, and they can range from as small as a pea to the size of a large grapefruit. These tumors are often found accidentally, as in this case, in ultrasounds ordered to look for something else. But they can cause symptoms and, rarely, even death.
To understand the harm, it is important to know the anatomy, Minella explained. The heart is divided into four chambers — the right side of the heart receives the oxygen-poor blood from the rest of the body. When the heart beats, the blood in the right side is squeezed into the lungs, where it is reloaded with oxygen. When the heart relaxes, that newly oxygenated blood flows into the left side of the heart. Both sides are divided into two parts: the atrium, a thin walled chamber that receives the blood, and the more muscular ventricle, which pushes the blood to its next stop, either the lungs (from the right side) or the rest of the body (from the left side). These tumors can have tiny clots on their surface. If the mass is on the left side of the heart — where most are — a loosened clot could travel to the brain and cause a stroke. If on the right side, where this patient's mass was seen, the clot would travel to the lung, cutting off blood flow there.
Less common but more concerning was the possibility of obstruction within the heart. When the heart squeezed with each beat, the mass would be pushed toward the valve that separates the atrium from the ventricle. If it somehow blocked that opening, no blood would be able to get through. That was probably what happened to her in the beauty parlor, Minella explained. That episode was most likely caused by this sudden loss of blood flow to the brain. And when she stumbled, she jostled the mass out of the valve, and the blood flow resumed. The myxoma looked as if it was just the right size to block that opening. She was lucky it hadn't happened more often.
The tumor would have to be removed as soon as possible, Minella told the patient and her husband. The risk was small but real. The surgery took place three days later. The surgeon had to cut her chest wide open from neck to the bottom of her sternum. Only then could he safely remove the tumor.
Once the woman was home, her friend Sandi came by to see her. Sandi had been worried since the woman first described what the ultrasound showed. When Sandi got home from the funeral, she read up on those tumors. That's why she called Minella's office that afternoon. She wanted to make sure that the next funeral she went to wasn't her friend's.
As for the patient, she feels great. After the surgery, she wasn't able to ride her bike or work in her garden for a couple of months — not until her chest healed. But once she recovered from that, she was fine. It is still hard for her to imagine that she could have something so large and so dangerous in her heart and not even know it. Minella didn't think that the pain she had — the one that led to the ultrasound — had anything to do with the tumor. So what would have happened if she hadn't gotten that ultrasound? She worried about that for a while, but now she finds that she is too busy enjoying her life to worry anymore.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is "Diagnosis: Solving the Most Baffling Medical Mysteries." If you have a solved case to share, write her at [email protected].