Near-Fatal Hemodynamic Collapse during Recovery from Staged Bladder Tumor Resection in a Patient with Giant Left...

Surgical management of a large, obstructive left atrial (LA) myxoma coexisting with an active bleeding source presents a significant clinical dilemma. The systemic heparinization required for cardiopulmonary bypass (CPB) carries a high risk of exacerbating hemorrhage, whereas delaying cardiac surgery leaves the patient vulnerable to fatal myxoma-related complications.

A 77-year-old woman presented with gross hematuria from an 8-cm bladder tumor. Preoperative evaluation revealed a giant (74 × 40 mm) LA myxoma prolapsing through the mitral valve, causing functional mitral stenosis. A multidisciplinary team elected for a "urology-first" staged approach. Transurethral resection of the bladder tumor (TURBT) was performed under general anesthesia with successful hemostasis. However, 30 min after extubation, the patient developed acute respiratory failure and cardiogenic shock due to myxoma incarceration. She was stabilized with noninvasive positive pressure ventilation and fluid management before being transferred to the ICU. Emergency myxoma resection was performed 18 h later. No significant bladder bleeding occurred despite full heparinization.

This case demonstrates that the post-anesthesia recovery period is a window of extreme vulnerability for patients with obstructive myxomas, likely due to emergence-related tachycardia. The "urology-first" staged approach, while logical for bleeding control, failed to prevent a life-threatening cardiac event. Accumulating evidence suggests that bleeding risk following adequate hemostasis at TURBT is low, even under anticoagulation. For patients with high-risk cardiac lesions, an immediate sequential surgical strategy-proceeding directly to cardiac surgery under the same anesthesia once non-cardiac hemostasis is achieved-should be strongly considered to minimize the duration of risk.