Cardiac Masses in Echocardiography: A Pragmatic Review

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.

Differential diagnosis of thrombosis and myxoma in unusual heart positions by dual-energy CT multiple parameter imaging: A case series

RATIONALE

Thrombus is the most common occupying lesion in the cardiac chambers, it is often distinguished from cardiac neoplastic occupations. Among them, the most common is cardiac myxoma, whose imaging manifestations are often confused with thrombus. However, the 2 types of lesions have different therapeutic strategies and are both potentially high-risk sources of embolism, so early differentiation between intracardiac thrombus and cardiac tumor is essential. In this study, we intend to investigate the value of dual-energy computed tomography (CT) in the differential diagnosis of cardiac thrombus and myxoma by retrospectively analyzing the dual-energy CT-related parameters of 2 cases of intracardiac thrombus and 1 case of cardiac myxoma.

PATIENT CONCERNS

Three cases of masses located in uncommon areas of the heart with comparable imaging characteristics are presented in this study.

DIAGNOSES

Echocardiography revealed an isoechoic mass in the cardiac chambers, while CT scans showed a hypodense occupancy with varying morphologies. Postoperative pathology or follow-up after treatment confirmed 1 case as a right ventricular thrombus, another as a right atrial thrombus, and the third as a right ventricular myxoma.

INTERVENTIONS

In this study, we conducted a retrospective analysis of dual-energy CT-related parameters in 2 cases of intracardiac thrombus and 1 case of cardiac myxoma.

OUTCOMES

Our findings indicate notable differences in the slopes of the energy spectral curves, mean iodine density, and effective atomic number between the intracardiac thrombus and myxoma cases.

LESSONS

Drawing upon existing literature, we propose combining different quantitative analysis methodologies to create a more objective foundation for distinguishing between cardiac thrombosis and myxoma.

A Case Report of Right Atrial Thrombosis Complicated by Multiple Pulmonary Emboli: POCUS For the Win!

A 78-year-old gentleman presented to the emergency department (ED) for palpitations and dizziness. He had a complicated medical history including atrial fibrillation (AF), recently status post a Watchman procedure, oxygen-dependent chronic obstructive pulmonary disease (COPD), and heart failure with preserved ejection fraction (HFpEF). Point-of-care ultrasound (POCUS) revealed the presence of an intracardiac right atrial thrombus. Computed tomography (CT) angiography confirmed the presence of multiple pulmonary emboli (PE), and extension of the thrombus into the inferior vena cava. Pulmonary emboli are a common complication of thrombus in the right atrium. Management may include anticoagulation, thrombolysis, or thrombectomy. This case highlights that emergency physicians can expedite the diagnosis of intracardiac thrombus by using POCUS. The case presented describes a medically complex patient presenting with symptomatic right intracardiac and inferior vena caval thrombosis complicated by multiple PE. Point-of care ultrasound of the heart and lungs were included in his initial assessment, revealing findings of an intracardiac thrombus, and ruling out multiple other differential diagnoses including pericardial tamponade, pleural effusion, pulmonary edema, and pneumothorax. This finding changed the trajectory of this patient's evaluation and management, and demonstrates the important role of POCUS in the care of ED patients with undifferentiated cardiopulmonary symptoms.

Topics

Point-of care ultrasound (POCUS), focused cardiac ultrasound (FOCUS), inferior vena cava thrombosis, right atrial thrombosis, pulmonary embolism, computed tomography, echocardiography.

The Therapeutic Potential of Different Surgical Approaches in the Management of Cardiac Myxoma: A Systematic Review

Background: Cardiac myxomas are benign tumors of the heart. They occur mostly in the left atrium. The preferred treatment is surgical resection, which can be performed via conventional median sternotomy, minimally invasive, or robotic-assisted approaches. This study aimed to evaluate the outcomes, advantages, and limitations of these surgical methods, with a focus on their safety, efficacy, and impact on patient recovery. Methods: This systemic review was conducted according to PRISMA guidelines. The chosen databases were systematically searched using the keywords "cardiac myxoma", "resection", "approach", "minimally invasive", and "robotic surgery". The comparison between the surgical strategies was based on thirteen articles, which met the inclusion criteria. Results: Median sternotomy remains the standard technique, providing excellent surgical access but is associated with longer hospital stays, higher blood loss, and increased risk of complications such as stroke. Minimally invasive approaches demonstrated comparable safety with shorter ICU stays, reduced blood loss, and lower postoperative pain but presented challenges, including limited exposure and longer procedure times. Robotic-assisted surgery showed potential as a safe alternative but was limited by high costs and technical demands. However, the data on minimally invasive and robotic methods are limited due to the rarity of cardiac myxomas. Conclusions: The choice of surgical technique should be individualised by considering the tumour size, location, patient condition, and surgeon expertise. Routine postoperative echocardiographic monitoring is essential to detect residual or recurrent tumours. Further studies are needed to validate the long-term efficacy of minimally invasive and robotic approaches.

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.

Hot Air Balloon in the Left Atria

A 54-year-old patient with a medical history of hypertension, dyslipidemia, and diabetes underwent mitral valve replacement surgery with a biologic valve. During a chest computed tomography scan for breast neoplasia staging, a reduced luminal filling in the left atrium (3.6 cm) was unexpectedly found, prompting further cardiac evaluation. The patient was referred to the emergency department experiencing shortness of breath and fatigue, which improved after furosemide administration, and remaining stable throughout hospitalization. A transesophageal echocardiogram was performed the following day and revealed a biologic mitral valve prosthesis slightly displaced toward the left ventricle with an average transprosthetic gradient of 7 mmHg. Notably, a sizable intermediate echogenic mass measuring 3.0 cm × 3.5 cm was detected and attached to the prosthesis ring in a lateral and posterior position, within the left atrium. A mild degree of periprosthetic regurgitation was also noted. Given the substantial suspicion that the observed mass was a thrombus, the patient was commenced on anticoagulation therapy while awaiting cardiac magnetic resonance imaging for better characterization of the mass. Over 4 weeks, the thrombus notably decreased in size, disappearing entirely by the 6th week. This case highlights the significance of employing multiple imaging techniques in managing cardiac masses. The incidental discovery of the mass, its characterization, and subsequent management through anticoagulation, followed by confirmation and monitoring through echocardiogram, underscore the importance of a multimodal approach in diagnosing and treating such conditions.

A rare morphology of the cardiac fibroma in a child: a case report

Here we report a rare morphology of a cardiac fibroma in a child. A 2-year and 8-month-old toddler came for "chronic constipation" and was found to have a heart murmur on cardiac auscultation. Further transthoracic echocardiography suggested "a strong echogenic mass in the left ventricular wall, with some part of "a string of beads" in shape extending into left ventricle outflow tract", which was atypical for either a tumor, thrombus or vegetation. The child underwent resection of the mass and mitral valvuloplasty. Pathological examination confirmed the mass as a cardiac fibroma.

What echocardiographic findings differentiate acute pulmonary embolism and chronic pulmonary hypertension?

BACKGROUND

Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival. Both conditions share several echocardiographic findings of right ventricular dysfunction. This can inadvertently lead to incorrect diagnosis, inappropriate and potentially harmful management, and delay in time-sensitive therapies. Fortunately, bedside echocardiography imparts a few critical distinctions.

OBJECTIVE

This narrative review describes eight physiologically interdependent echocardiographic parameters that help distinguish acute PE and chronic PH. The manuscript details each finding along with associated pathophysiology and summarization of the literature evaluating diagnostic utility. This guide then provides pearls and pitfalls with high-quality media for the bedside evaluation.

DISCUSSION

The echocardiographic parameters suggesting acute or chronic right ventricular dysfunction (best used in combination) are: 1. Right heart thrombus (acute PE) 2. Right ventricular free wall thickness (acute ≤ 5 mm, chronic > 5 mm) 3. Tricuspid regurgitation pressure gradient (acute ≤ 46 mmHg, chronic > 46 mmHg, corresponding to tricuspid regurgitation maximal velocity ≤ 3.4 m/sec and > 3.4 m/sec, respectively) 4. Pulmonary artery acceleration time (acute ≤ 60-80 msec, chronic < 105 msec) 5. 60/60 sign (acute) 6. Pulmonary artery early-systolic notching (proximally-located, higher-risk PE) 7. McConnell's sign (acute) 8. Right atrial enlargement (equal to left atrial size suggests acute, greater than left atrial size suggests chronic).

CONCLUSIONS

Emergency physicians must appreciate the echocardiographic findings and associated pathophysiology that help distinguish acute and chronic right ventricular dysfunction. In the proper clinical context, these findings can point towards PE or PH, thereby leading to earlier goal-directed management.

Papillary Muscle Lipoma in a Teenage Patient With Review of the Literature

•Cardiac lipoma is exceedingly rare in both adult and pediatric populations. •Only a few cases of papillary muscle lipoma have been reported. •TTE is the first step in detecting a cardiac mass. •CMR contributes to the diagnosis of cardiac lipoma. •There are no specific guidelines for the treatment of papillary muscle lipoma.

Case Report: Right atrial organized thrombus three years after tricuspid annuloplasty

Background: Occurrence of right atrial masses, especially in patients with history of cardiac surgery, is rare. Differential diagnosis between malignant and non-malignant aetiologies might be cumbersome, and surgery is often required to prevent complications or disease evolution. Case: We report the case of a 16-year-old girl from a rural area of Sudan, who underwent surgery for a modified De Vega's tricuspid annuloplasty, and mitral and aortic valve replacement with mechanical prostheses. The patient was on regular follow-up but demonstrated a poor compliance to anticoagulation therapy with a time in therapeutic range between 52% and 20%. She remained asymptomatic, but a right atrial mass was diagnosed by transthoracic echocardiography during a follow-up visit 41 months after the first operation. Surgical removal of the mass revealed an organized thrombus arising from the point where the Prolene stitches for the tricuspid annuloplasty were previously passed. The patient recovered from surgery, was discharged home on post-operative day 10 and the first follow-up visit at 30 days after discharge confirmed a good clinical status and a normal transthoracic echocardiography (TTE). Conclusions: This case report describes the diagnostic and therapeutic work-out of a thrombus formation on the suture lines of a tricuspid annuloplasty. Moreover, it highlights the importance of a strict and long follow-up after valvular surgery and of the adherence to anticoagulation therapy, especially for patients living in rural areas of developing countries.

Diagnosis and treatment of a left atrial myxoma originating from an atrial septal defect closure device: a case report

Background

Ostium secundum atrial septal defect (osASD) is a common congenital heart disease and transcatheter closure is the preferred treatment. Late device-related complications include thrombosis and infective endocarditis (IE). Cardiac tumours are exceedingly rare. The aetiology of a mass attached to an osASD closure device can be challenging to diagnose.

Case summary

A 74-year-old man with atrial fibrillation was hospitalized for evaluating a left atrial mass discovered incidentally 4 months earlier. The mass was attached to the left disc of an osASD closure device implanted 3 years before. No shrinkage of the mass was observed despite optimal intensity of anticoagulation. We describe the diagnostic workup and management of the mass that at surgery turned out to be a myxoma.

Discussion

A left atrial mass attached to an osASD closure device raises the suspect of device-related complications. Poor endothelialisation may promote device thrombosis or IE. Cardiac tumours (CT) are rare, and myxoma is the most common primary CT in adults. Although no clear relationship exists between the implantation of an osASD closure device and a myxoma, the development of this tumour is a possible occurrence. Echocardiography and cardiovascular magnetic resonance play a key role in the differential diagnosis between a thrombus and a myxoma, usually identifying distinctive mass features. Nevertheless, sometimes non-invasive imaging may be inconclusive, and surgery is necessary to make a definitive diagnosis.

The Role of Multimodality Imaging in the Diagnosis and Follow-Up of Malignant Primary Cardiac Tumors: Myxofibrosarcoma-A Case Report and Literature Review

Cardiac tumors are a very rare but heterogenous group of diseases that may reveal themselves through a variety of nonspecific cardiac symptoms that may pose a challenge to the diagnostic process. Myxofibrosarcoma is a particularly rare type of cardiac tumor that carries a poor prognosis, thus making accurate and timely diagnosis essential. A 61-year-old woman presented with fatigue and shortness of breath during mild exercise, symptoms that have progressively worsened during the previous year. Multimodality imaging consisting of transthoracic and transesophageal echocardiography (TTE and TEE), cardiac magnetic resonance (CMR), cardiac computer tomography (CCT), and fluorodeoxyglucose positron emission computer tomography (18F-FDG PET-CT) was used for the diagnosis and postoperative follow-up of a myxofibrosarcoma.

Approach to Cardiac Masses Using Multimodal Cardiac Imaging

Incidental cardiac masses can pose diagnostic challenges given the numerous differentials, and difficulty in obtaining tissue confirmation without invasive procedures. With recent advancements in cardiac imaging technology, non-invasive efforts to diagnose the intracardiac lesions have become more surmountable. In this paper, we report a case of a patient incidentally found to have an intra-cardiac mass during routine evaluation. Transthoracic echocardiography demonstrated a small mass attached to the tricuspid valve, which was not visualized on follow up cardiac magnetic resonance imaging. Here, we review the currently available cardiac imaging modalities and discuss their values and limitations. From this, we also propose a workflow in the approach to utilizing different imaging modalities to reach a conclusive diagnosis of undifferentiated cardiac masses.

Incidental right atrial mass in a patient with secondary pancreatic cancer: A case report and review of literature

BACKGROUND

The incidental detection of a right atrial mass during routine cardioncological workup is a rare condition. The correct differential diagnosis between cancer and thrombi is challenging. A biopsy may not be feasible while diagnostic techniques and tools may not be available.

CASE SUMMARY

We report the case of a 59-year-old female patient with a history of breast cancer and current secondary metastatic pancreatic cancer. She developed deep vein thrombosis and pulmonary embolism and was admitted to the Outpatient Clinic of our Cardio-Oncology Unit for follow-up. Transthoracic echocardiogram incidentally found a right atrial mass. Clinical management was difficult due to the abrupt worsening of the patient’s clinical condition and the progressive severe thrombocytopenia. We suspected a thrombus, according to its echocardiographic appearance, the patient’s cancer history and recent venous thromboembolism. The patient was unable to adhere to low molecular weight heparin treatment. Due to worsening prognosis, palliative care was recommended. We also highlighted the distinguishing features between thrombi and tumors. We proposed a diagnostic flowchart to aid diagnostic decision making in the case of an incidental atrial mass.

CONCLUSION

This case report highlights the importance of cardioncological surveillance during anticancer treatments to detect cardiac masses.

Hiatal Hernia: The Great Masquerade in the Emergency Department

Chest pain and dyspnoea are among the most common complaints seen in the emergency room and each symptom calls for a broad differential diagnosis. Large hiatal hernias are infrequent, but they can lead to atypical symptoms mimicking different cardiovascular, pulmonary and neoplastic diseases. We present two cases of older patients with an apparent left atrial mass on transthoracic echocardiography, which was subsequently identified as hiatal hernia by other imaging modalities. A multidisciplinary team with multimodality imaging is necessary for diagnostic work-up of chest pain and dyspnoea of non-cardiac origin and especially for a suspected mass compressing the heart, causing chest discomfort.

LEARNING POINTS

Hiatal hernia (HH) can mimic different cardiovascular, pulmonary and neoplastic diseases.HH has a typical echocardiographic (2DE) presentation as an amorphous, echolucent mass with the appearance of a left atrial space-occupying lesion.Oral ingestion of a carbonated drink may help to distinguish between a large HH and an atrial mass by 2DE.

A rare case of left atrial myxofibromyosarcoma

Myxofibrosarcoma is an aggressive soft tissue sarcoma, previously known as myxoid variant of malignant fibrous histiocytoma. Primary cardiac myxofibrosarcomas are the rarest forms of cardiac malignant tumors that often remain asymptomatic until metastasis occurs. In this case report, we describe a rare left atrial cardiac myxofibrosarcoma in a patient with recurrent renal cell carcinoma. We discuss the multimodality imaging approach to diagnose and evaluate cardiac masses as well as imaging characteristics to differentiate cardiac masses from thrombus.

Metastatic Melanoma Extending along the Pulmonary Vein into the Left Atrium: A Rare Route of Metastasis Characterized by Transesophageal Echocardiography

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Melanoma commonly metastasizes to the heart through hematogenous spread.

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These metastases can resemble benign cardiac tumors.

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Isolated left-sided cardiac involvement is rare with metastatic melanoma.

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Metastasis can atypically take a course through the pulmonary vein.

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Multimodality imaging is useful for characterization of these intracardiac masses.

Concomitant Multiple Coronary Artery Embolizations and Bilateral Lower Limb Ischemia due to Dislodged Left Atrial Myxoma-Like Thrombus

The differential diagnosis of intracardiac masses is challenging. Cardiac myxomas are benign primary heart tumors and most often are confused with thrombi in diagnosis. In some cases, the embolic complication of intracardiac masses can be fatal. We present a patient who had two nightmare complications simultaneously. A mobile left atrial mass detected and decided surgical excision. But the mass had vanished one day after and caused ST-elevation myocardial infarction (STEMI) and bilateral lower limb ischemia.

Membranous Ventricular Septal Aneurysm Leading to Embolic Stroke

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TTE is often ordered to assess for a cardiac source of emboli after an acute stroke.

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MVSAs may lead to blood stasis and thrombus formation.

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Color Doppler and UEAs may be used to confirm or exclude the presence of thrombus.

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.

Asymptomatic Left Atrial Myxoma Treated With Minimally Invasive Surgical Approach

Myxomas, being the most common primary benign tumor among all cardiac tumors, occur rarely with a very low incidence rate. Myxomas can cause various clinical manifestations or can be diagnosed incidentally. Some patients with cardiac myxomas are completely asymptomatic. Cardiac myxomas cause life-threatening complications, thus early diagnosis is imperative. We are reporting a case of atrial myxoma in a 38-year-old female without any significant past medical history, who came to our clinic for cardiology evaluation prior to plastic surgery. The elliptical mobile mass, located in the left atrium with its attachment to the interatrial septum, was diagnosed by transthoracic echocardiography. The patient was referred for surgery and a minimally invasive surgical approach was chosen. A histological report confirmed the diagnosis of myxoma. The patient recovered well. Three years of follow-up did not reveal any signs of recurrence of the tumor. We are also analyzing 20 previously published cases of asymptomatic myxomas and myxomas treated with a minimally invasive surgical approach, reported in the PubMed database for the last 20 years (2001-2021) in the adult patient population (age 19 and over). The aim of this study is to highlight the asymptomatic presentation of cardiac myxomas and to underline the advantages of a minimally invasive surgical approach. In summary, asymptomatic cardiac myxomas are rare incidental findings. Attention to subtle symptoms during a physical exam and scrupulous history-taking can provide a clue to this diagnosis. Early diagnosis of cardiac myxomas is crucial to prevent life-threatening complications. Minimally invasive surgery is a promising alternative approach to standard open-heart surgery for treating cardiac myxomas, providing faster recovery and higher patient satisfaction with surgical care.