Abstract Body (Do not enter title and authors here): Introduction: Atrial myxomas are cardiac tumors that can cause arterio-occlusive diseases due to embolization of myxomatous fragments. Treatment is through prompt surgical resection, with recurrence rates relatively rare. Herein, we present a case of recurrent left atrial myxoma with hemorrhagic, cerebral embolization.

Case Report: A 34-year-old male presented with acute onset numbness and tingling of the left arm. He was vitally stable with unremarkable physical examination or bloodwork. CT Head showed multifocal brain metastases in the bilateral parietal and left frontal lobes. Brain MRI demonstrated multiple hemorrhagic masses throughout the cerebral hemispheres with vasogenic edema. The patient’s past medical history was pertinent for bilateral occlusion of the femoral and popliteal arteries, with workup revealing a left atrial myxoma that was surgically resected in 2005. The patient presented again in 2021 with right facial paresthesia and arm weakness. Brain MRI showed bilateral cortical and subcortical MCA ischemic strokes. TEE confirmed the recurrence of a left atrial myxoma, requiring a repeat sternotomy and resection.

Since then, the patient was frequently hospitalized with seizures and strokes. Surveillance brain MRIs consistently demonstrated hemorrhagic masses of varying sizes and vasogenic edema, localized to the watershed territories of the cerebral arteries. The patient underwent left frontal craniotomy and resection of a left frontal lobe lesion in 2023, with pathology specimens representing organizing cerebral hemorrhage of unclear etiology. Repeat echocardiograms did not show recurrence of a myxoma. The overwhelming clinical opinion states that these are myxomatous metastasis from before the patient’s last cardiac surgery. Given the tumor burden and progressive nature of the disease, the patient was deemed inappropriate for neurosurgery or chemotherapy.

Discussion: Recurrence after surgical resection of atrial myxomas is rare, with 0.5 cases reported per 1000-person years, and is mainly attributed to inadequate surgical resection. Limited research exists regarding malignant atrial myxomas. The prevailing hypothesis points to the neoplastic transformation of myxomatous emboli into malignant lesions. Our patient is a unique case of a recurrent atrial myxoma with symptomatic cerebral metastasis. This case highlights the importance of adequate resection of cardiac myxomas to prevent the malignant transformation of an otherwise benign tumor.