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A 61-year-old man with an uneventful medical history presented with two transient ischaemic attacks (TIA) with bulbar and peripheral deficit. Transthoracal and transoesophageal echocardiography revealed a patent foramen ovale (PFO) and a large, lobulated, pedunculated, non-calcified, and heterogenic mass attached to the septal tricuspid leaflet (Panels 1–3) with important mobility.

MRI suggested a myxoma, being isointense on T1-weighted turbo spin echo (TSE), iso-hyperintense on T2-weighted TSE, and hypointense on spoiled gradient echo. First-pass perfusion showed a heterogeneous and hypoperfused enhancement pattern, while contrast-enhanced inversion recovery images showed diffuse hyperenhancement (Panels 4 and 5). Carotid echo-Doppler, Holter monitoring, and a normally contracting left atrial appendage devoid of thrombus excluded other aetiologies for TIA. Cardiac surgery was performed with PFO closure and tumour excision, including the peduncle and the middle part of the septal leaflet.

Biopsy showed a firm, multilobular, and smooth-surfaced tumour. Cut-sections revealed a white-yellowish, collagen-rich myxoid tissue, containing several vascular caverns and focal hemorrhages (Panel 6). Histological sections confirmed the diagnosis of a myxoma, containing multiple vascular structures (Panel 7) as well as spindle and stellate cells with pale ovoid nuclei in a loose myxoid stroma (Panel 8A), some arranged as primitive vessels (Panel 8B). Immunohistochemistry showed stellar and fusiform cells positive for S100 (Panel 8B and C) and CD34 (Panel 8D).

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