Unusual Coexistence of Takayasu Arteritis, Diffuse Coronary Aneurysms, and a Large Left Atrial Myxoma in an Elderly Male: A Case Report and Literature Review.

Takayasu arteritis (TA) is a form of vasculitis that primarily affects the large arteries of the body. Involvement of the coronary arteries is uncommon, whereas cardiac myxomas are benign growths within the heart that can cause problems by embolization or by obstruction. Both diseases are rare, and coexistence of both is exceptionally uncommon. An 84-year-old man with a 30-year history of TA (type V) on low-dose prednisone and weekly methotrexate was found to have a large left atrial myxoma in addition to diffuse coronary aneurysms on routine follow-up. The increased inflammatory markers, erythrocyte sedimentation rate (ESR) 52 mm/h and C-reactive protein (CRP) 18 mg/L, and magnetic resonance imaging (MRI) of the thoracic aorta (wall thickening with mural enhancement of the ascending aorta and arch) confirmed active vasculitis. His modified National Institutes of Health (NIH) score was 5 (active TA). Echocardiography revealed a mass, measuring 3.5 × 3.0 cm in size, arising from the left atrium. The mass caused mild mitral inflow obstruction resulting in a mean transmitral gradient of 3.5 mmHg across the valve and mild to moderate regurgitation. The estimated pulmonary artery pressure was mildly elevated at 34 mmHg. The patient was, however, asymptomatic and had a good functional status. The coronary arteries were significantly dilated. The left anterior descending (LAD) artery was chronically occluded, and the right coronary artery (RCA) was dilated, forming a huge aneurysm. Given the patient's age, any surgical approach would be associated with prohibitive risk. Thus, management of the coronary artery abnormalities in this patient with active TA consisted of immunosuppressive therapy, anticoagulation, and guideline-directed medical therapy (GDMT) for hyperlipidemia. This case highlights the importance of a comprehensive inflammatory and hemodynamic assessment of the patient with TA before any surgical intervention can be considered. In an elderly patient with active disease and in stable hemodynamic condition, even a large, mobile atrial myxoma with mild hemodynamic impact may be managed conservatively with anticoagulation and close surveillance when surgical risk is prohibitive.