Cardiac Masses: The Role of Cardiovascular Imaging in the Differential Diagnosis

Preoperative multimodal imaging evaluation of a primary cardiac schwannoma of the right atrioventricular groove: a case report

Background

Cardiac schwannoma is exceedingly rare, and few literature reports are available. We reported a case of primary cardiac schwannoma that performed preoperative multimodal imaging, aiming to highlight the significance of multimodal imaging evaluation and deepen our understanding of this tumour.

Case summary

A 66-year-old man presented to our hospital, as physical examination revealed the presence of a mediastinal mass over a month. Subsequently, the patient underwent comprehensive examination. The images demonstrated the mass compressed the right coronary artery, but no invasion. Resection of the tumour by surgery was conducted, and the patient remains asymptomatic at follow-up.

Discussion

This case emphasizes the role of multimodal imaging in preoperative evaluation of such rare cardiac tumours. For benign cardiac schwannoma, the preferred treatment is surgical resection.

Cardiac myxoma: a comprehensive review

Heart tumours are a diverse group of tumours that may present with symptoms or be discovered incidentally when a patient is being evaluated for a physical or seemingly unrelated ailment. Cardiac myxoma, although rare, is the second most common benign primary cardiac tumours after papillary fibroelastoma. It occurs in sporadic form and familial form, as seen in Carney complex disorder. Cardiac myxoma can affect all age groups, but the majority manifests in their third to sixth decade of life, with a mean age of 50 years at diagnosis. There is a slight preponderance in females in a ratio of 2:1. Conversely, they are incredibly uncommon in fetuses and newborns but commonly diagnosed in children around a mean age of 9-10 years. About 90% originate in the atrium as a solitary or pedunculated mass. Within the atrial chamber, 75% occur on the left atrium close to the fossa ovalis, while others occur in the right atrium, ventricles, and valves. Serious complications often arise even in the absence of symptoms, and such complications include intracardiac obstruction, systemic and pulmonary emboli, as well as constitutional symptoms that mimic connective tissue and inflammatory diseases. There is no pathognomonic clinical presentation. Complete surgical excision of the tumour, including the use of robotic surgery, is the key component of a successful course of treatment. To monitor for tumour recurrence, long-term follow-up is frequently carried out with interval echocardiography. This review will focus on providing information on the various forms of cardiac myxoma, aetiology, molecular genetics, clinical presentation, histopathologic findings, differential diagnosis, treatment, and complications.

Cardiac Metastasis: Epidemiology, Pathophysiology, and Clinical Management

Cardiac metastases (CMs) are more common than primary cardiac tumors, with autopsy studies reporting incidence rates between 2.3% and 18.3%. Their increasing detection is largely attributed to advances in cancer treatments, which have extended patient survival. CMs may present with diverse clinical manifestations depending on their size, location, and extent of infiltration, although they often remain asymptomatic and are identified only postmortem. Sometimes, they are incidentally discovered during tumor staging or follow-up evaluations. This review explores the incidence, pathophysiology, clinical features, and potential complications of CMs, focusing on their prevalence and characteristics. It highlights the importance of early detection and optimized management strategies to address this growing clinical concern. Further research is essential to elucidate the mechanisms driving CMs and develop effective therapeutic interventions.

Integration and Potential Applications of Cardiovascular Computed Tomography in Cardio-Oncology

PURPOSE OF REVIEW

Cardiovascular computed tomography (CCT) is a versatile, readily available, and non-invasive imaging tool with high-resolution capabilities in many cardiovascular diseases (CVD). Our review explains the increased risk of CVD among patients with cancer due to chemoradiotherapies, shared risk factors and cancer itself and explores the expanding role of CCT in the detection, surveillance, and management of numerous CVD among these patients.

RECENT FINDINGS

Recent research has highlighted the versatility and enhanced resolution capabilities of CCT in assessing a wide range of cardiovascular diseases. Early detection of cardiac changes and monitoring of disease progression in asymptomatic patients with cancer may lessen the severity of CVD. It offers an essential means to assess for coronary artery disease when patients are either unable to safely undergo stress testing for ischemia evaluation or at risk of complications from invasive coronary angiography. Furthermore, CCT extends its utility to valvular diseases, cardiomyopathies, pericardial diseases, cardiac masses, and radiation-induced cardiovascular diseases, allowing for a comprehensive, noninvasive assessment of the entire spectrum of cancer treatment associated CVD. Looking to the future, the integration of artificial intelligence and machine learning algorithms holds potential for automated image interpretation, improved precision and earlier detection of subclinical cardiac deterioration, allowing opportunities for earlier intervention and disease prevention. CCT is a useful imaging modality for assessing the myriad cardiovascular manifestations of diseases such as coronary artery disease, cardiomyopathies, pericardial disesaes, cardiac masses and radiation-induced cardiovascular diseases. CCT has several advantages. Readily available non-cardiac chest CT scans of patients with cancer may help with improved cardiovascular care, enhanced ASCVD risk stratification and toxicity surveillance.

Right atrial thrombus in a neonate with Aspergillus colonization secondary to central venous catheter: a case report

Background

Central venous catheter-related thrombosis (CRT) is a recognized complication, particularly in patients with underlying hypercoagulable states. This condition can precipitate several complications, including secondary infections, necessitating immediate and effective diagnosis and management.

Case summary

In this report, we present a case of a 13-day-old neonate admitted to the neonatal intensive care unit with severe respiratory distress, necessitating the insertion of a central venous catheter for optimal nutrition and treatment. Persistent fever and worsening general condition prompted further investigations, including echocardiography, which revealed a sizeable right atrial mass. Surgical removal of the mass was performed, and subsequent analysis identified thrombosis complicated by Aspergillus colonization. Postoperative management included anticoagulation and antifungal therapy, which were continued for 3 weeks until the patient's condition improved, leading to discharge.

Discussion

This case highlights the importance of accurate differential diagnosis of cardiac masses, early recognition and management of CRT in neonates, and the need for timely treatment of opportunistic infections like invasive Aspergillosis for optimal outcomes.

Case Report: A rare diffuse mitral valvular myxoma

Cardiac myxoma is a common benign tumor, however, myxoma extensively distributed on the mitral valve is rare and seldom reported. A patient who presented with exertional dyspnea and chest tightness was examined by transthoracic and transesophageal echocardiography successively. Multiple neoplasms on the mitral valve with moderate mitral regurgitation were found and were further proved to be a diffuse myxoma on the mitral valve by histology. Three-dimensional transesophageal echocardiography provided a precise evaluation of the mitral valve neoplasms, contributing to clinical decision-making.

The Diagnostic and Therapeutic Dilemma of Multiple Left Ventricular Masses

Intracardiac masses are rare and potentially life-threatening entities with diverse clinical presentations. The prompt identification of cardiac masses is critical. However, even with the advancement we have in imaging modalities, diagnosing cardiac masses remains a formidable challenge. Herein, we present the case of a 62-year-old female who presented with a three-week history of dyspnea and chest pain. Further workup revealed elevated troponins, thrombocytosis, and ST-segment elevation in the anterolateral leads. Chest CT revealed a concerning lung mass, along with vertebral lesions and a large pleural effusion. The patient underwent treatment for suspected myocardial infarction. Additional imaging identified five intracardiac masses in the left ventricle suspicious for either malignancy or thrombi. High-intensity heparin drip was started, yet the patient developed neurological symptoms. Neuroimaging showed new cerebral infarcts. Based on the patient and her family's wishes, the patient transitioned to comfort care and passed away from gastrointestinal bleeding. In our case, the patient's presentation raised questions about whether her intracardiac masses were malignant or thrombotic. The decision to initiate and maintain anticoagulation therapy constitutes a debate, emphasizing the need for an individualized approach and shared decision-making with the patient and the multidisciplinary team.

Primary Cardiac Aggressive B-Cell Lymphoma Affecting Right Ventricle and Acute Cardiovascular Events: Multidisciplinary Approach

Primary cardiac lymphoma (PCL) is extremely rare. A few reviews comprise the available evidence. We present the case of a 70-year-old man who was immunosuppressed as a result of a previous liver transplant and who presented with PCL. This case highlights the cardiovascular issues that clinicians may face in PCL management and the importance of a multidisciplinary team approach.

Multimodal Imaging Approach to Atrial Myxoma to Optimize Surgical Management

Cardiac masses are rare and of the neoplastic group, myxomas are the most common. An elderly male with a background of multiple myeloma and previous autologous stem cell transplant presented with dyspnea and chest heaviness with a subsequent cardiac mass found. Multimodal imaging, including three-dimensional (3D) echocardiography and cardiac magnetic resonance (CMR) imaging, was utilized to guide the diagnostic process, particularly given the differential of a cardiac plasmacytoma in the setting of multiple myeloma. CMR was used to identify characteristic features of the mass and 3D echocardiography highlighted the anatomical relationships of the mass in relation to surrounding structures to complement surgical planning. The different imaging approaches and clinical decision-making were implemented to aid in definitive surgical management.

Cardiac interventricular septum hemangioma in a colon cancer patient treated with Capecitabine: A case report and review of literature

We report a case of a 21-year-old male with stage IIIB sigmoid colon adenocarcinoma who experienced atypical chest pain post-adjuvant chemotherapy with Capecitabine (5-FU prodrug). Evaluation revealed an unexpectedly detected interventricular septum hemangioma. Due to the vasospasm effect of chemotherapy presenting with semi-ischemia, conservative management was chosen for atypical presentation.

Imaging in Infective Endocarditis-Current Opinions and Trends in Cardiac Computed Tomography

Infective endocarditis is a rare disease with an increasing incidence and an unaltered high mortality rate, despite medical development. Imaging plays an integrative part in the diagnosis of infective endocarditis, with echocardiography as the initial diagnostic test. Research data in the utility of cardiac computed tomography (CCT) in the diagnostic algorithm of IE are rising, which indicates its importance in detection of IE-related lesion along with the exclusion of coronary artery disease. The latest 2023 European Society of Cardiology Guidelines in the management of IE classified CCT as class of recommendation I and level of evidence B in detection of both valvular and paravalvular lesions in native and prosthetic valve endocarditis. This review article provides a comprehensive and contemporary review of the role of CCT in the diagnosis of IE, the optimization of acquisition protocols, the morphology characteristics of IE-related lesions, the published data of the diagnostic performance of CCT in comparison to echocardiography as the state-of-art method, as well as the limitations and future possibilities.

Multimodality Imaging of Cardiac Myxomas

Cardiac myxomas are the most common benign cardiac neoplasms. Echocardiography is the first-line imaging modality used to analyze cardiac masses, allowing the detection of tumor location, size, and mobility. However, additional imaging techniques are required to confirm the diagnosis, evaluate tissue characteristics of the mass, and assess potential invasion of surrounding structures. Second-line imaging includes cardiac magnetic resonance imaging (MRI) and/or computed tomography (CT) depending on availability and the patient's characteristics and preferences. The advantages of CT include its wide availability and fast scanning, which allows good image quality even in patients who have difficulty cooperating. MRI has excellent soft-tissue resolution and is the gold standard technique for noninvasive tissue characterization. In some cases, evaluation of the tumor metabolism using 18F-fluorodeoxyglucose positron emission tomography with CT may be useful, mainly if the differential diagnosis includes primary or metastatic cardiac malignancies. A cardiac myxoma can be identified by its characteristic location within the atria, typically in the left atrium attached to the interatrial septum. The main differential diagnoses include physiological structures in the atria like crista terminalis in the right atrium and the coumadin ridge in the left atrium, intracardiac thrombi, as well as other benign and malignant cardiac tumors. In this review paper, we describe the characteristics of cardiac myxomas identified using multimodality imaging and provide tips on how to differentiate myxomas from other cardiac masses.

Cardiac myxoma following transcatheter closure of an atrial septal defect

To date, no significant association has been reported between atrial septal defects (ASD) and cardiac myxomas. This study reports a 56-year-old woman with cardiac myxoma following transcatheter closure of ASD. She presented with a 3-month history of recurrent dizziness, vertigo, palpitations, and generalized weakness after undergoing ASD occlusion a year earlier. Echocardiography and cardiac computed tomography scans identified a large, mobile mass (7.2 cm × 2.8 cm) in the left atrium, protruding through the mitral valve. The patient underwent median sternotomy and pericardiotomy, and the histopathological examination confirmed the diagnosis of atrial myxoma. The current case illustrates the challenges in determining whether an atrial mass is a benign myxoma or a dangerous thrombus. While there is no definitive link between the implantation of an ASD closure device and the formation of a myxoma, the emergence of this tumor is a potential occurrence.

A rare presentation of primary cardiac myxofibrosarcoma: Case report and literature review

BACKGROUND

Primary cardiac myxofibrosarcoma is a rare and aggressive malignancy, with the majority of approaching strategies relying on case reports. This article provides insights into its diagnosis and treatment.

CASE PRESENTATION

This paper presents the case of a 40-year-old man with sudden onset hemoptysis, leading to the diagnosis of primary cardiac myxofibrosarcoma. Treatment involved open-heart surgery to excise the left atrium tumor, followed by 6 cycles of adjuvant chemotherapy. Unfortunately, brain metastasis developed, leading to the patient's death 1 year after initial diagnosis.

CONCLUSION

Primary cardiac myxofibrosarcoma remains a clinical challenge with an unfavorable prognosis. Early diagnosis through advanced imaging is crucial, and research is needed to explore innovative treatments. This case underscores the complexities of managing this rare cardiac malignancy and highlights the necessity for ongoing investigations to enhance patient outcomes.

The usefulness of contrast echocardiography in the evaluation of cardiac masses: a multicenter study

BACKGROUND

Cardiac masses can encompass a variety of conditions, such as tumors, thrombi, vegetations, calcific lesions, and other rare diseases. Treatment and management of these types of cardiac masses differ considerably. Thus, accurately distinguishing among thrombi, benign tumors, and malignant tumors in the heart is of great importance. Contrast echocardiography (CE) has emerged as a promising technology. Although published guidelines suggest that CE can enhance image quality and assist in differentiating between benign and malignant lesions, most studies on CE diagnosis of cardiac masses are limited to case reports or retrospective/small-sample-sized prospective cohorts. This study aims to evaluate the diagnostic accuracy of CE in patients with suspected cardiac masses and address the insufficient evidence for differential diagnosis using CE.

METHODS

Between April 2018 and July 2022, a prospective multicenter study was conducted, which included 145 consecutive patients suspected to have cardiac masses based on transthoracic echocardiography. All patients underwent CE examinations. The echocardiographic diagnosis relied on qualitative factors such as echogenicity, boundary, morphology of the base, mass perfusion, pericardial effusion, and motility as well as quantitative factors such as the area of the masses and the peak intensity ratio of the masses to adjacent myocardium (A1/A2).

RESULTS

The final confirmed diagnoses were as follows: 2 patients had no cardiac mass, 4 patients had pseudomass, 43 patients had thrombus, 66 patients had benign tumors, and 30 patients had malignant tumors. The receiver operating characteristic (ROC) analysis indicated that an optimal A1/A2 cutoff value of 0.499 distinguished a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.977, 97.9%, 90.7%, 95.9%, and 95.1%, respectively. The optimal A1/A2 cutoff value of 1.583 distinguished a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.950, 93.3%, 93.9%, 87.5%, and 96.9%, respectively.

CONCLUSIONS

Combined with qualitative and quantitative analyses, CE has the potential to accurately differentiate among different types of cardiac masses.

Diagnostic Pathway From Incidental Mass to Metastatic Melanoma: Role of Multimodal Imaging and Medical Therapy

We present a case of detection of a right atrial mass during surveillance echocardiography, mimicking myxoma. Cardiac magnetic resonance and computed tomography revealed infiltration into the pericardium, suggesting malignancy. Abdominal computed tomography showed multiple liver masses that were histologically positive for metastatic amelanotic melanoma. Under immunotherapy adequate remission was achieved.

Cardiac Masses and Pseudomasses: An Overview about Diagnostic Imaging and Clinical Background

A cardiac lesion detected at ultrasonography might turn out to be a normal structure, a benign tumor or rarely a malignancy, and lesion characterization is very important to appropriately manage the lesion itself. The exact relationship of the mass with coronary arteries and the knowledge of possible concomitant coronary artery disease are necessary preoperative information. Moreover, the increasingly performed coronary CT angiography to evaluate non-invasively coronary artery disease leads to a rising number of incidental findings. Therefore, CT and MRI are frequently performed imaging modalities when echocardiography is deemed insufficient to evaluate a lesion. A brief comprehensive overview about diagnostic radiological imaging and the clinical background of cardiac masses and pseudomasses is reported.

Rare Case Report: Left Atrial Sarcoma Obstructing the Left Ventricular Inflow

Malignant cardiac tumors of the heart are extremely rare and may present tremendous diagnostic and therapeutic challenges. These tumors are able to infiltrate the heart and metastasize systemically. Early detection is often elusive as the clinical presentation is highly variable, posing significant diagnostic and therapeutic difficulties. Despite a multidisciplinary approach, the prognosis for patients with malignant cardiac tumors remains guarded. Early diagnosis and a multidisciplinary approach involving cardiac surgeons, oncologists and critical care specialists are crucial in the management of this disease. Further research is needed to better understand the pathomechanisms of tumor-related complications and to develop effective treatment strategies to improve patient outcomes. The rare case of a 78-year-old woman with left atrial tumor requiring emergency surgery for acutely developing mitral valve obstruction is presented. Pathology confirmed an undifferentiated pleomorphic sarcoma. This patient tragically did not survive, highlighting the difficulties of managing such a rare and deceptive heart disease.

Cardiovascular Magnetic Resonance Versus Histopathologic Study for Diagnosis of Benign and Malignant Cardiac Tumours: A Systematic Review and Meta-Analysis

BACKGROUND

The gold standard for diagnosis of cardiac tumours is histopathological examination. Cardiovascular magnetic resonance (CMR) is a valuable non-invasive, radiation-free tool for identifying and characterizing cardiac tumours. Our aim is to understand CMR diagnosis of cardiac tumours by distinguishing benign vs. malignant tumours compared to the gold standard.

METHODS

A systematic search was performed in the PubMed, Web of Science, and Scopus databases up to December 2022, and the results were reviewed by 2 independent investigators. Studies reporting CMR diagnosis were included in a meta-analysis, and pooled measures were obtained. The risk of bias was assessed using the Quality Assessment Tools from the National Institutes of Health.

RESULTS

A total of 2,321 results was obtained; 10 studies were eligible, including one identified by citation search. Eight studies were included in the meta-analysis, which presented a pooled sensitivity of 93% and specificity of 94%, a diagnostic odds ratio of 185, and an area under the curve of 0.98 for CMR diagnosis of benign vs. malignant tumours. Additionally, 4 studies evaluated whether CMR diagnosis of cardiac tumours matched specific histopathological subtypes, with 73.6% achieving the correct diagnosis.

CONCLUSIONS

To the best of our knowledge, this is the first published systematic review on CMR diagnosis of cardiac tumours. Compared to histopathological results, the ability to discriminate benign from malignant tumours was good but not outstanding. However, significant heterogeneity may have had an impact on our findings.

MR imaging of primary benign cardiac tumors in the pediatric population

Primary cardiac tumors are rare in all ages, especially in children, with a reported prevalence range of 0.0017-0.28% in autopsy series. Due to their rarity, the diagnostic and therapeutic pathways reserved to them are usually described by single case reports, leading to the point where a common diagnostic protocol is imperative to obtain a differential diagnosis. The first diagnostic approach is done with transthoracic echocardiogram (TTE), due to its wide availability, low cost, absence of ionizing radiations and non-invasiveness. Several tumors are discovered incidentally and, in many cases, TTE is helpful to determine location, size and anatomical features, playing a key role in the differential diagnosis. In the last few years, cardiac magnetic resonance imaging (CMR) has had an increased role in the diagnostic pathway of pediatric cardiac masses, due to its high accuracy in characterizing mass tissue properties (especially for soft tissue), and in detecting tumor size, extent, pericardial/pleural effusion, leading to the correct diagnosis, treatment and follow-up. Therefore, nowadays, several consensus statements consider CMR as a leading imaging technique, thanks to its non-invasive tissue characterization, without the use of ionizing radiation, in an unrestricted field of view. As suggested by the most recent literature, the pediatric protocol is not so different from the adult one, adapted to the size and cardiac frequency of the patient, sometimes requiring special conditions such as free-breathing sequences and/or sedation or general anesthesia in non-cooperating patients.

Role of integrated imaging in the diagnosis of an atypical and unresectable cardiac paraganglioma: a case report

BACKGROUND

Paragangliomas (PGLs) are rare neuroendocrine tumours that originate from extra-adrenal location. Cardiac PGLs can cause severe hypertension, palpitations, and lethal tachyarrhythmias. Diagnosis is based on measurement of plasma or urine metanephrines combined with conventional and nuclear imaging. Effective treatment is represented by surgical resection. We report a case of a 19-year-old patient with recurrent acute pericarditis; integrated imaging detected a large cardiac mass suggestive for PGL.

CASE SUMMARY

A 19-year-old male suffered pleuritic chest pain and fever for 4 days; electrocardiogram showed inferior ST elevation and transthoracic echocardiography a 2.2 cm pericardial effusion; these findings led to diagnose acute pericarditis. After a relapse of pericarditis, cardiac magnetic resonance and cardiac computed tomography (CCT) were performed, revealing a cardiac mass with radiological features of PGL. Blood and urine tests detected elevated levels of 3-methoxytyramine and chromogranin A. Gallium-68 positron emission tomography confirmed high metabolic activity of the mass. A negative 123-I-MIBG scintigraphy ruled out the possibility of radiometabolic treatment. A second CCT excluded the chance of surgical resection, due to intra-lesional course of the left anterior descending coronary artery. The young patient was referred to a different centre to achieve reduction of the mass, in order to potentially resect it afterwards.

DISCUSSION

Cardiac PGLs are rare tumours with significant morbidity related to norepinephrine secretion. In this case, without typical clinical manifestations and with no chance of surgical resection, integrated imaging played a central role in the differential diagnosis between PGL and other cardiac masses, providing both static and dynamic characterization.

A Rapidly Growing Cardiac Mass-Malignant or Benign?

•Rapidly growing cardiac tumors can be benign or malignant. •Rarely, cardiac myxomas may grow rapidly, causing heart failure or obstructive symptoms. •Echocardiography remains the first-line imaging for cardiac tumors. •Multimodality imaging with CCT, CMR, and PET may aid in diagnosis.

Cardiac osteosarcoma: a case report and literature review

Background

Primary cardiac tumors are rare, and malignant primary cardiac tumors are even rarer. Cardiac osteosarcoma is a very rare type of malignant primary cardiac tumor with limited reported cases. We present a case report of cardiac osteosarcoma and review its characteristics and the related literature.

Case summary

A 44-year-old female patient without a specific medical history presented with intermittent dyspnea that started 1 month prior to presentation. A heterogeneous mass was observed in the left atrium on echocardiography and a large mass was observed in the left atrium on computed tomography. Surgery was performed under the suspicion of atypical cardiac myxoma, and the tumor was successfully removed. However, postoperative histopathological examination revealed cardiac osteosarcoma. The patient underwent chemotherapy and has been well maintained without recurrence for 10 years.

Conclusion

We present a case report of the echocardiographic features and treatment strategies for cardiac osteosarcoma, an extremely rare cardiac tumor. Multimodal imaging can be helpful; however, a histological diagnosis through surgical resection is essential. Appropriate treatment and follow-up based on histological findings are necessary.

Practical Guide to Interpreting Cardiac Magnetic Resonance in Patients with Cardiac Masses

It is common for a cardiac mass to be discovered accidentally during an echocardiographic examination. Following the relief of a cardiac mass, being able to evaluate and characterize it using non-invasive imaging methods is critical. Echocardiography, computed tomography (CT), cardiac magnetic resonance imaging (CMR), and positron emission tomography (PET) are the main imaging modalities used to evaluate cardiac masses. Although multimodal imaging often allows for a better assessment, CMR is the best technique for the non-invasive characterization of tissues, as the different MR sequences help in the diagnosis of cardiac masses. This article provides detailed descriptions of each CMR sequence employed in the evaluation of cardiac masses, underlining the potential information it can provide. The description in the individual sequences provides useful guidance to the radiologist in performing the examination.

Diagnosis of the right atrial myxoma after treatment of COVID-19: A case report

Key Clinical Message

Atrial myxoma is a rare disease but has a broad clinical presentation and complication that involves several systems- heart, lungs, brain, and systemic. An interdisciplinary approach is very important to optimize the outcome in patients with atrial myxomas. A thorough examination by primary care providers is crucial. Then radiologists or cardiologists can help with imaging modalities that can help diagnose and characterize the tumor. Prior to surgical resection by cardiothoracic surgeons, patients need to be evaluated by pulmonologists, cardiologists, and anesthesiologists for preoperative risk stratifications. In patients with neurological complications, pulmonary complications, or infectious endocarditis, input from neurologists, hematologists, infectious disease specialists is essential for patient care. In case antiplatelet/anticoagulation therapy or antibiotic treatment is warranted, pharmacists can provide valuable recommendations.

Abstract

Myxoma is the most common benign cardiac primary tumor, occurring in the right atrium in only 15%-20% of cases. This disease is asymptomatic initially depending upon size of the tumor, and symptoms develop as the tumor spreads. Atrial myxomas are associated with a triad of complications, including obstruction, emboli, and constitutional symptoms (such as fever and weight loss). This regard, embolization of the pulmonary circulation system is a complication of right myxoma. The patient was a 40-year-old male who presented to the emergency department complaining of fever and confusion. He had been previously hospitalized due to COVID-19 and treated with Remdesivir and plasmapheresis. He had tachycardia, tachypnea, thrombocytopenia, and increased liver enzymes. Chest imaging showed nodular lesions with necrotic areas and cavitary lesions in both lungs and the right atrium infected clot was seen in echocardiography. He was treated with intravenous antibiotics and finally underwent heart surgery due to the diagnosis of pulmonary septic embolism. The patient was finally diagnosed with right atrial myxoma according to heart mass histopathology. It is worth noting that the patient's thrombosis had already developed on the right atrial myxoma, which delayed the diagnosis in this patient. This thrombus formation was due to the hypercoagulability state of COVID-19 and following the insertion of a central venous catheter to perform plasmapheresis as a complication of treatment. Special attention should be paid to thromboprophylaxis and the early diagnosis of intravascular and intracardiac thrombosis in COVID-19 patients. Furthermore, the use of imaging modalities is recommended to differentiate thrombus from myxoma.

Magnetic Resonance Imaging in the Study of Cardiac Masses: A Case Series

Cardiac masses are currently studied using multimodality imaging. For diagnosis, different imaging techniques that can provide complementary information are used. Cardiac magnetic resonance imaging (MRI) has become a fundamental tool for this type of pathology owing to its ability to provide tissue characterization, spatial accuracy, and the anatomic relationships of the different structures. This study presents a series of four clinical cases with an initial diagnosis of a cardiac mass. All cases were evaluated at a single center, and patients were aged 57 to 72 years. An etiological study was conducted on all patients using different imaging techniques, including MRI. This study describes the diagnostic and therapeutic procedures of the four cases, which included two intracardiac metastases and two benign tumors. Cardiac MRI was decisive in the diagnostic process, determining the clinical decision-making in all four cases. Cardiac MRI has emerged as a pivotal technique in the diagnosis of cardiac masses. It can provide a highly accurate histological diagnosis without the need for invasive techniques.

Multiple Imaging and Surgical Characteristics in Cardiac Metastasis from Undifferentiated Uterine Sarcoma

Although cardiac metastasis of malignant tumors has often been reported, undifferentiated uterine sarcoma (UUS) is a rare and aggressive uterine tumor. Thus, little is known of the UUS as a primary site of cardiac metastasis. We report a case of a 66-year-old woman, with a history of uterine myoma for 30 years, who was hospitalized with a large uterine tumor and cardiac masses. Although we investigated cardiac masses using imaging modalities, such as ultrasound, cardiac computer tomography, and magnetic resonance imaging, it was challenging to determine the masses as metastasis or thrombi. Cardiac masses were removed by surgery to assess the tissue characteristics and were later identified as tumors due to their appearance. Then, pathological findings revealed that UUS spreads to the right ventricle. We attempted chemotherapy after surgery; however, the disease progressed very quickly and the patient died on the 49th day of admission. In this report, we described the case of a patient with a difficult diagnosis and rapid disease progression of cardiac metastasis from UUS.

Differential diagnosis of cardiac tumors: General consideration and echocardiographic approach

Cardiac tumors may be primary (either benign or malignant) or secondary (malignant) and are first detected by echocardiography in most cases. The cardiologist often challenges their identification, the differential diagnosis and the best therapeutic approach. Malignant tumors have usually a poor prognosis, which may be significantly improved by appropriate and timely therapies. The echocardiographic aspects of benign and malignant cardiac tumors described in this article, along with a clinical evaluation may orient the differential diagnosis and aid in choosing the further steps useful to define the nature of the mass.

The diagnostic accuracy of contrast echocardiography in patients with suspected cardiac masses: A preliminary multicenter, cross-sectional study

Background

To evaluate the diagnostic accuracy of contrast echocardiography (CE) in patients with suspected cardiac masses.

Methods

A multicenter, prospective study involving 108 consecutive patients with suspected cardiac masses based on transthoracic echocardiography performed between November 2019 and December 2020 was carried out. CE examinations were performed in all patients. The echocardiographic diagnosis was established according to the qualitative (echogenicity, boundary, morphology of the base, mass perfusion, pericardial effusion, and motility) and quantitative (area of the masses and peak intensity ratio of the masses and adjacent myocardium A1/A2) evaluations.

Results

Final confirmed diagnoses were as follows: no cardiac mass (n = 3), pseudomass (n = 3), thrombus (n = 36), benign tumor (n = 30), and malignant tumor (n = 36). ROC analysis revealed the optimal A1/A2 with cutoff value of 0.295 for a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.958 (95% confidence interval (CI): 0.899–0.988), 100, 91.7, 95.7, and 100%, respectively. CE was able to distinguish malignant from benign tumors with an AUC of 0.953 (95% CI: 0.870–0.990). Multivariate logistic regression analysis revealed that tumor area, base, and A1/A2 were associated with the risk of malignant tumor (OR = 1.003, 95% CI: 1.00003–1.005; OR = 22.64, 95% CI: 1.30–395.21; OR = 165.39, 95% CI: 4.68–5,850.94, respectively). When using A1/A2 > 1.28 as the only diagnostic criterion to identify the malignant tumor, AUC, sensitivity, specificity, PPV, and NPV were 0.886 (95% CI: 0.784–0.951), 80.6, 96.7, 96.7, and 80.7%, respectively.

Conclusion

CE has the potential to accurately differentiate cardiac masses by combining qualitative and quantitative analyses. However, more studies with a large sample size should be conducted to further confirm these findings.

Clinical trial registration

http://www.chictr.org.cn/, identifier: ChiCTR1900026809.

Cardiac Rhabdoid Tumor—A Rare Foe—Case Report and Literature Review

Intracardiac masses are unusual findings in infants, and most of them are benign. Nevertheless, they may be associated with a significant degree of hemodynamic instability and/or arrhythmias. Malignant tumors of the heart rarely occur in children. Rhabdoid tumors are aggressive tumors with a dismal prognosis even when diagnosed early. Although rhabdomyomas are common cardiac tumors in infants, they are mostly benign. The most common sites of involvement are the kidneys and central nervous system, but soft tissues, lungs, and ovaries may also be affected. The diagnosis can be challenging, particularly in sites where they do not usually occur. In the present paper, we report the case of a 2-year-old boy diagnosed with cardiac rhabdoid tumor highlighting the importance of molecular studies and recent genetic discoveries with the purpose of improving the management of such cases. The aim of this educational case report and literature review is to raise awareness of cardiac masses in children and to point out diagnostic hints toward a cardiac tumor on various imaging modalities. Given the rarity of all tumors involving the heart and the lack of symptom specificity, a high degree of suspicion is needed to arrive at the correct diagnosis.

Massive Mural Thrombus Masquerading as Myxoma

A 75-year-old Caucasian female with a past medical history including insulin-dependent diabetes mellitus, hypertension, and dyslipidemia, presented to the emergency room for having palpitations for three weeks. Echocardiography revealed a very large left atrial mass mimicking myxoma. Mass was excised and examined by pathology, revealing a mural thrombus. A mural thrombus is not an uncommon mass found in the left atrium. However, it does not often present symptomatically, strongly mimics an atrial myxoma on cardiac imaging, and has rarely ever been reported to be greater than seven centimeters in any dimension. We present a case of a 75-year-old Caucasian woman with a massive, symptomatic cardiac thrombus masquerading as a myxoma on imaging.

Role of Echocardiography in Diagnosing Metastatic Testicular Carcinoma in a Young Patient Presenting as Right Heart Failure

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Metastatic GCTs may initially present as right heart failure.

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TTE and TEE can diagnose cardiac metastasis and monitor cardiac function.

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Multimodality imaging informs about tumor burden in metastatic cardiac tumors.

A study of 399 cardiac tumors: Characteristics of echocardiography and pathological features

AIMS

This study aimed to summarize the transthoracic echocardiography (TTE) characteristics of cardiac tumors with different pathologies.

METHODS

The data of 399 patients with cardiac tumors confirmed by pathology, who had undergone surgical resection were consecutively collected in our hospital between January 1, 2011 and December 31, 2019. The TTE characteristics were summarized and compared with the pathology.

RESULTS

Mean patient age was 49.8±15.7 years (22 children and 377 adults), and 62.2% were female. Of the tumors, 90.5% (361) were primary and 9.5% (38) were secondary. Further, 88.7% (354) were benign and 11.3% (45) were malignant. Of the primary tumors (96.1% benign and 3.9% malignant), 84.2% were myxomas, followed by 3.5% lipomas and 1.5% fibromas in adults, while in children, 31.8% were rhabdomyomas and 22.7% were fibromas. The most common type of secondary cardiac tumor was malignant liver carcinoma metastasis (39.5%) and benign intravenous leiomyomatosis with cardiac extension from the uterus (18.4%). TTE features of myxoma showed four variation types among 8.9% of myxomas: liquefaction (anechoic region mostly), calcification (hyperechoic range with a shadow), multiple nodules, and high proliferative activity (a large irregular mass with a wide base and a high Ki67 index). The TTE characteristics of some common benign non-myxoma tumors had specific findings. The TTE features of malignant tumors mostly showed hypoechogenicity, an unclear boundary, a wide basement, and multi-chambers or tissue invasion.

CONCLUSIONS

Most cardiac tumors have typical ultrasonic manifestations. Preoperative echocardiography could roughly judge cardiac tumor type and may be helpful for guiding clinical treatment decisions.

Cardiovascular magnetic resonance of cardiac tumors and masses

Cardiac masses diagnosis and treatment are a true challenge, although they are infrequently encountered in clinical practice. They encompass a broad set of lesions that include neoplastic (primary and secondary), non-neoplastic masses and pseudomasses. The clinical presentation of cardiac tumors is highly variable and depends on several factors such as size, location, relation with other structures and mobility. The presumptive diagnosis is made based on a preliminary non-invasive diagnostic work-up due to technical difficulties and risks associated with biopsy, which is still the diagnostic gold standard. The findings should always be interpreted in the clinical context to avoid misdiagnosis, particularly in specific conditions (e.g., infective endocarditis or thrombi). The modern multi-modality imaging techniques has a key role not only for the initial assessment and differential diagnosis but also for management and surveillance of the cardiac masses. Cardiovascular magnetic resonance (CMR) allows an optimal non-invasive localization of the lesion, providing multiplanar information on its relation to surrounding structures. Moreover, with the additional feature of tissue characterization, CMR can be highly effective to distinguish pseudomasses from masses, as well as benign from malignant lesions, with further differential diagnosis of the latter. Although histopathological assessment is important to make a definitive diagnosis, CMR plays a key role in the diagnosis of suspected cardiac masses with a great impact on patient management. This literature review aims to provide a comprehensive overview of cardiac masses, from clinical and imaging protocol to pathological findings.

Case Report: An Unusual Case of Biventricular Thrombosis in a COVID-19 Patient With Ischemic Dilated Cardiomyopathy: Assessment of Mass Mobility and Embolic Risk by Tissue Doppler Imaging

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein binds to angiotensin-converting enzyme 2 (ACE2) receptor on vascular cells. As a consequence, patients with COVID-19 have an increased incidence of thromboembolic complications of the SARS-CoV-2 infection and subsequent endothelial cell damage with consequence of development of systemic vasculitis and diffuse intravascular coagulation. The present case describes a COVID-19 female patient with ischemic dilated cardiomyopathy, who presented with congestive heart failure and echocardiographic evidence of biventricular apical thrombi. The peak antegrade longitudinal velocity (Va) of each thrombotic mass was measured by pulsed wave tissue Doppler imaging (PW-TDI). Both left ventricular and right ventricular apical thrombi were found with a TDI-derived mass peak Va < 10 cm/s. There was no clinical evidence of neither systemic nor pulmonary embolization, probably due to the hypomobility of both left and right ventricular masses.

Right atrial papillary fibroelastoma arising from the Chiari network detected by echocardiography: a case report and literature review

PURPOSE

To improve our understanding of cardiac papillary fibroelastoma(PFE)and provide evidence for its treatment and prognosis.

MATERIALS AND METHODS

We report a 54-year-old Chinese male who was hospitalized for a 14-day headache with a previous vertebral aneurysm history. A right atrial mass arising from the CN was detected by echocardiography and complete tumor resection was performed finally. Pathologic findings confirmed the diagnosis of cardiac papillary fibroelastoma. The recovery of the patient was uneventful and follow-up echocardiographic examination revealed no recurrence of the tumor.

RESULTS

Transthoracic echocardiography revealed a mobile, sessile mass in the right atrium without obstructing the orifice of the tricuspid valve. The subsequent transesophageal echocardiography confirmed the presence of a 1.56cm × 1.24cm mobile, sessile, irregular mass arising from the CN (Fig. 1) and showed no evidence of patent foramen ovale.

CONCLUSIONS

Early recognition and surgical excision is essential for patients with cardiac PFE.