Right Atrial Metastasis Mimicking Myxoma in Advanced Hepatocellular Carcinoma

Hepatocellular carcinoma is the most common primary tumor of the liver accounting for 4.6% of all new human cancers. Cardiac metastasis in hepatocellular carcinoma is an uncommon secondary cardiac malignancy. We described two cases of advanced hepatocellular carcinoma with large masses in the right atrium mimicking atrial myxoma. The RA masses were incidentally detected during two-dimensional echocardiographic examination. (Echocardiography 2010;27:80-83)     

IGG4-related giant lymphoproliferative-inflammatory left atrial mass

Cardiac masses are rare entities that can be challenging in clinical diagnosis and management. Cardiac masses can be detected incidentally in patients with an asymptomatic course or may cause systemic inflammation findings due to inflammatory cytokine release or symptoms such as shortness of breath, chest pain, syncope, sudden cardiac death, and mortality due to the location of the mass. Cardiac masses associated with systemic inflammatory disorders are uncommon in this disease group. This case report will present a case with an asymptomatic IgG4-related left atrial mass detected in routine echocardiographic control imaging due to rheumatic valve disease.     

Magnetic resonance imaging of suspected atrial tumors.

Two-dimensional echocardiography has become the standard technique for evaluation of cardiac and paracardiac mass lesions. We have used magnetic resonance imaging (MRI) as an independent assessment of cardiac-associated masses in patients with echocardiograms demonstrating sessile atrial tumors. MRI was performed in seven patients, ages 33 to 84, whose echocardiographic diagnoses included left atrial mass (five), right atrial mass (one), and interatrial mass (one). In four of the patients with a diagnosis of left atrial mass, MRI showed extracardiac compression of the atrium, simulating a tumor (hiatal hernia, tortuous descending aorta, bronchogenic cyst). MRI was entirely normal in one patient with an apparent left atrial mass. MRI elucidated extension of an extracavitary mass into the interatrial septum in two patients. One of these patients with an echocardiographic right atrial mass had extension of a lipoma into the interatrial septum without atrial tumor. MRI confirmed the echocardiographic diagnosis of an interatrial mass in the other patient. We conclude that MRI, because of its ability to define anatomic relationships and tissue characteristics, is a powerful noninvasive tool for evaluating suspected cardiac mass lesions. Although echocardiography remains the primary screening test for the detection of cardiac masses, MRI is a more specific modality for precise diagnosis. Correct MRI interpretation may obviate the need for invasive studies or surgery.     

Contained ascending aortic rupture disguised as a right atrial mass

Transesophageal echocardiography can incidentally detect cardiac masses. A right atrial mass has many possible causes, including metastatic extension from various solid organs, malignant melanoma, mediastinal cysts, hematoma, myxoma, lipoma, and artifact.Herein, we report our discovery of a right atrial mass during the initial intraoperative transesophageal echocardiographic examination of a patient who was undergoing repair of an ascending aortic aneurysm. The mass, with a smooth border and homogenous grayscale density, showed no flow during color-flow Doppler echocardiography. Further examination revealed tricuspid annular dilation and severe tricuspid insufficiency. When the mediastinum was opened, we found a large extracardiac hematoma along the right atrium within the pericardial space. These findings suggested an acute, contained rupture of the ascending aorta. After the hematoma was evacuated, imaging revealed complete resolution of the mass and reduction of tricuspid insufficiency. The patient underwent the scheduled aortic repair and was discharged from the hospital in good condition.In order to ensure an accurate diagnosis and to gain appropriate clinical guidance that can lead to a successful outcome, we suggest performing a thorough echocardiographic investigation to identify any such mass before planned surgery proceeds.     

Characterization of an Unusual Right Atrial Mass by Echocardiography, Magnetic Resonance Imaging, Computed Tomography, and Angiography

A right atrial mass was discovered by echocardiography in a 53-year-old man. A work-up consisting of magnetic resonance imaging and computed tomography studies established the diagnosis of atrial lipoma. The echocardiographic features are compared with the radiological findings, and the characteristics permitting differentiation of lipoma from other causes of cardiac masses are discussed. In this case, echocardiography not only permitted the initial identification of the mass but also proved to be useful in follow-up of its evolution over time, thereby influencing the therapeutic management.     

Unusual left atrial mass: inverted left atrial appendage caused by massive pericardial effusion

Left atrial appendage inversion is a very rare cause of left atrial mass that usually occur after cardiac surgery. Its echocardiographic appearance often misleads clinicians to the diagnosis of thrombus or cardiac neoplasms. Unfortunately, misdiagnosed patients often undergo unnecessary anticoagulation or surgical treatment. We are presenting a case of left atrial appendage inversion caused by massive pericardial effusion in a patient with no previous history of cardiac surgery together with demonstrative images of transesophageal echocardiography and magnetic resonance imaging.     

Massive right atrial myxoma

Right atrial myxomas are uncommon and are often detected incidentally in asymptomatic individuals. We describe a case of a massive right atrial myxoma that was suspected following an abnormal right heart border on a chest X-ray and an abnormal 12 lead electrocardiogram.     

Intracardiac masses detected by echocardiography: case presentations and review of the literature

Intracardiac masses are often diagnosed by transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) improves overall visualization of masses, especially those located in the posterior cardiac structures. Masses in the heart are most commonly due to thrombi or valvular vegetations; however, a variety of tumors may also present as cardiac masses on echocardiography. Tumors of the heart most commonly occur in the setting of metastatic disease, usually from malignancies of the breast, lung, or from malignant melanoma. Primary cardiac tumors occur much less frequently and are usually benign. Atrial myxomas constitute nearly one-half of reported primary cardiac tumors. The following discussion details the findings of five cases that illustrate the spectrum of intracardiac tumors detected by echocardiography and reviews the relevant literature.     

A pedunculated left ventricular hemangioma initially misdiagnosed as thrombus in a woman with atypical chest pain

The incidence of cardiac masses increased as echocardiography is becoming increasingly popular. Benign tumors of the heart constitute about 72% of all primary cardiac neoplasms and hemangioma accounts for 5–10% of benign cardiac tumors. Cardiac hemangiomas are generally asymptomatic and diagnosed incidentally during echocardiography or magnetic resonance imaging (MRI). We reported a 52-year-old woman presented with atypical chest pain and exertional dyspnea. The echocardiographic examination revealed a hyperechoic round mass in the left ventricle. With an initial diagnosis of left ventricular thrombus, the patient underwent cardiac MRI. The mass was found compatible with cardiac hemangioma. It was removed surgically and histopathologic evaluation identified a cardiac hemangioma. As reports of cardiac hemangioma are extremely rare and cardiac masses are mostly thought to be thrombi or myxomas (being the most common primary cardiac tumor), such hemangioma cases warrant attention as possibility of hemangioma should also be kept in mind.     

Primary Cardiac Angiosarcoma with Spontaneous Ruptures of the Right Atrium and Right Coronary Artery

Primary tumors of the heart are rarely seen. Cardiac angiosarcomas are malignant tumors that almost always have a poor prognosis. Atrium rupture and coronary artery fistula are very rare complications of primary cardiac angiosarcoma. We describe a 57‐year‐old man suffering from primary cardiac angiosarcoma with spontaneous ruptures of the right atrium and right coronary artery (RCA). Theoretically, either of these ruptures invariably results in pericardial effusion and tamponade that is rare but potentially life threatening. In this instance, however, the patient might have developed fibrous adhesions resulted from previous bloody pericardial effusion. A massive pericardial effusion was localized, which consequently prevented cardiac tamponade and hemodynamic collapse. Echocardiography revealed the tumor progression leading to detectable infiltration of solid mass into the right atrial (RA) wall, which is close to RCA. And color Doppler displayed the flow into the pericardial cavity through a disrupted RA wall and perforated RCA. Echocardiography remains the primary method of choice for evaluation of cardiac masses.     

Transesophageal versus transthoracic echocardiography in the evaluation of right atrial tumors

The purpose of this study was to define the contribution of transesophageal echocardiography to the diagnosis of right atrial tumors in a large series of patients with this rare finding. Transesophageal echocardiography (TEE) has been found to be valuable in evaluating patients with intracardiac masses and has been shown ton be superior to transthoracic echocardiography (TTE) in evaluating left heart masses. Between 1989 and 1993, 23 patients with either known tumors elsewhere or right atrial masses that were detected on TTE were evaluated with TEE. TEE studies were performed in the noninvasive cardiology laboratory. All patients were studied with 5 MHz biplane or omniplane transducers. The right atrium was evaluated for the presence, characteristics, extent, and attachment of any masses and for extension of these masses into the great vessels or other cardiac chambers. No complications occurred. Six patients had primary right atrium tumors. In 10 patients the tumors reached the right atrium via the inferior vena cava. Seven patients had malignant secondary tumors. TEE demonstrated three tumors not detected by TTE. Furthermore TEE provided 16 additional findings not seen on TTE. In conclusion, TEE is superior to TTE in the evaluation of right atrial tumors. TEE should be considered in patients with right atrial tumors even when these tumors have been demonstrated with TTE.     

Large Mass in Left Atrium by Transesophageal Echocardiography: An Unusual Case of Cardiac Angiosarcoma Mimicking a Cystic Mass

Primary cardiac tumors are extremely rare. Among them, malignant tumors constitute approximately 15% of primary cardiac tumors. Angiosarcomas are the most frequent. They often appear as mural masses in the right atrium and completely replace the atrial wall and fill the entire cardiac chamber. We report an unusual case of angiosarcoma in a 75‐year‐old woman with a cystic appearance, located in the left atrium and causing critical mitral stenosis. (Echocardiography 2010;27:E137‐E138)     

Thromboses of the right atrium: echocardiographic aspects, practical management. Apropos of 8 cases

Right atrial (RA) thrombosis is rare. The aim of this study was to determine their clinical and echocardiographic features and therapeutic implications. In the last 7 years, 16 RA masses were detected by 2D echocardiography. The diagnosis of thrombosis was made in 8 cases based on anatomo-pathological examination (6 cases) or their disappearance with medical treatment (2 cases). The clinical presentations were: pulmonary embolism (4 cases), anterior myocardial infarction (2 cases), Ebstein's anomaly (1 case), thrombosis of a Leveen catheter (1 case). Only 1 patient had atrial fibrillation. Two echocardiographic appearances were observed: 1) a long, very mobile thrombus floating between the RA and right ventricle (4 cases), 2) a relatively immobile mass (4 cases). The 4 patients with relatively immobile thrombi survived: 2 underwent surgery and 2 were treated medically. All cases of floating thrombi had pulmonary embolism: 2 patients underwent surgery but the postoperative course was complicated; 2 patients died suddenly before surgery. These cases show that 2D echo is the diagnostic method of choice for detection of RA thrombosis. The floating RA thrombus is a therapeutic emergency and has a poor prognosis.     

The role of echocardiography in the management of the sources of embolism

The echocardiographic diagnosis of cardiac thrombi, vegetations and tumors as well as the identification of predisposing conditions such as patent foramen ovale, aortic atherosclerosis and other minor causes (e.g., mitral valve prolapse, mitral and aortic valve calcification) have crucial clinical relevance, affecting the choice of surgery and/or of pharmaceutical therapy in the setting of patients presenting embolism. The echocardiographic assessment helps not only for the retrospective diagnosis of sources of embolism but also for the prevention of events in asymptomatic patients. Echocardiography can also distinguish normal variants and artifacts from cardiac masses and tumors. Echocardiographic characterization/typology of cardiac sources of embolism is currently below par when compared with cardiac MRI, the current gold standard. Nevertheless, echocardiography remains the 'first-line' imaging tool, because of its low cost and the possibility to add easily available, functional and structural information at the patient's bedside.     

Calcified mass in the right atrium extending into the inferior vena cava with pulmonary artery embolization. Typical or atypical myxoma?

Cardiac masses are divided into neoplastic and non-neoplastic. They usually represent a diagnostic challenge given their relative rarity, their infrequent symptoms, and the overall difficulty with dynamic imaging of the heart. While echocardiography is useful in the initial evaluation of a suspected mass, cardiac magnetic resonance (CMR) imaging is the best imaging modality to characterize cardiac tumors due to its superior tissue characterization and its higher contrast resolution. For neoplastic, primary cardiac tumors are rare (0.05%). Atrial myxoma is the most common cardiac (50%) mass. About 75%-80% of myxoma are seen in the left atrium. Atypical myxoma is a term describing myxoma arising in other nonleft atrial locations. 20%-25% myxomas arise from the right atrium and 5% or less from the ventricles. We present a case of a 59-year-old female patient presenting with severe dyspnea. Her chest noncontrast CT showed a calcified mass lesion in the right atrium extending into the inferior vena cava. She underwent cardiac MRI for better tissue characterization. The cardiac MRI revealed a very irregular, highly spiculated, heavily calcified, heterogeneous, and nonenhancing lesion within the right atrium extending into the inferior vena cava. Via dynamic imaging, no evidence of mobile components was present. Via T1, T2 along with pre- and postcontrast imaging, the mass was confirmed to be calcified without a fibrotic component or evidence of thrombus. The above findings raised the possibility of atypical myxoma.     

Clinical presentation and non-invasive diagnosis of right heart masses.

Right-sided cardiac masses do not have a uniform clinical presentation. Successful diagnosis is dependent on a high index of suspicion and appropriate echocardiographic examination. Five cases of right sided intracardiac masses have been detected during the period that echocardiography has been routinely available to us--two of right atrial myxoma, one of right atrial thrombus, and two of right ventricular tumour. M-mode echocardiography identified four of the five cases. Two-dimensional echocardiography was necessary to establish the non-invasive diagnosis in the fifth case. Echocardiography should be used in any patient in whom a right sided mass is suspected, or in those patients presenting with signs of tricuspid regurgitation, tricuspid stenosis, pulmonary stenosis, cyanotic heart disease, progressive right heart failure, constrictive pericarditis, or pulmonary emboli without obvious source.     

Kidney tumour mimicking cardiac mass

The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis between a primary cardiac tumour (with myxoma being the most frequent), invasion of an extracardiac tumour, vegetations on the tricuspid valve, and an atrial thrombus. We describe the case of a patient who was admitted to our service with a diagnosis of suspected myxoma based on the chance transthoracic echocardiographic discovery of a right atrial mass. A transesophageal echocardiogram showed the process to be extracardiac, and magnetic resonance imaging showed it to originate at the renal level extending via the inferior vena cava to the right atrium. Tumour extension with thrombosis of the vena cava is a relatively frequent complication of renal carcinoma, but only exceptionally does it reach the right atrium. It is also exceptional that this was a chance finding in an asymptomatic patient.     

Echocardiographic diagnosis of right atrial tamponade

We report the case of a 27-year-old man who developed isolated right atrial tamponade eight weeks following aortic valve replacement. The diagnosis was made by two-dimensional and contrast echocardiography and was subsequently confirmed by cardiac catheterization and surgery. Right atrial tamponade presents a unique conglomeration of clinical, hemodynamic, and echocardiographic features. Constant awareness of this entity is necessary to make a timely diagnosis.     

Giant congenital right atrial epithelioid‐capillary hemangioma with prolonged QT interval: Case report and practical surgical treatment strategy for primary cardiac tumors in children based on 25‐year review of 299 cases

Cardiac hemangioma is very rare and accounts for 2%–3% of the primary cardiac tumors. Cardiac epitheloid‐capillary hemangioma has not been reported in the pediatric population so far. We report the fatal outcome of a preterm neonate with a huge congenital right atrial epitheloid‐capillary hemangioma and elevated serum alpha‐fetoprotein, associated with prolonged QT interval. We describe the echocardiographic, computed tomographic (CT) imaging, microscopic and immunohistochemical features of the tumor. Complete resection of the tumor was done at operation necessitating extensive reconstruction of atrial walls. Intramural infiltration of this tumor into the surrounding myocardial walls is a challenging characteristic of cardiac hemangioma. The temptation to complete resection should be avoided in the setting of extensive intramural infiltration and entrapment of the tumoral cells into atrial walls, particularly in a preterm neonate. None of the current classifications for hemangioma was inclusive of our case. Based on a concise literature review of nine published classification systems from 1996 to 2017 , we discuss the shortcomings of the current classifications for hemangioma. We also performed a 25‐year‐review of 299 cases of primary cardiac tumors in neonates and children, from 1993 to May 2018. We suggest a stepwise surgical treatment strategy according to the characteristics of the patient and of the tumor, based on this review. The stepwise strategy includes watchful observation, partial resection, complete resection and cardiac transplantation.