Percutaneous transvenous biopsy for the diagnosis of a right atrial myxoma

Intracardiac tumors are generally diagnosed by transthoracic echocardiography, transesophageal echocardiography and, more recently, magnetic resonance imaging. However, these techniques do not permit a histopathologic diagnosis. When surgery is not indicated because of limited hemodynamic changes but the benign nature of the tumoral mass is questionable, percutaneous transvenous biopsy, when technically feasible, may represent an alternative approach. In this case report, we utilized percutaneous transvenous biopsy to obtain specimens from a right atrial mass in a 39-year-old woman.     

Transseptal Biopsy of a Left Atrial Mass with 3-Dimensional Transesophageal Echocardiographic Guidance

A 31-year-old man presented with a large cardiac mass that originated from the basal posterior left atrial wall and occupied most of the dilated atrium. Minimally invasive studies yielded inconclusive results, but the patient was considered at high risk for an open cardiac biopsy due to the size of the mass. To establish a tissue diagnosis for definitive treatment, we performed a transseptal cardiac biopsy guided by 3-dimensional transesophageal echocardiography. We thereby determined that the mass was a primary left atrial sarcoma. To the best of our knowledge, this is the first report concerning the use of 3-dimensional transesophageal echocardiography for biopsy of a left atrial mass.Key words: Biopsy/methods, echocardiography, 3-dimensional, echocardiography, transesophageal, heart atria/ultrasonography, heart neoplasms/diagnosis, sarcoma/diagnosis, tumors, cardiacCardiac tumors are infrequently encountered in clinical practice. Treatment options are guided by location, stage, and tissue diagnosis. If imaging does not provide a conclusive diagnosis, a biopsy is performed. In obtaining specimens for biopsy, the operator encounters more difficulty with left-sided than with right-sided masses. We describe a left atrial tumor in which the biopsy specimen was obtained by means of a transseptal puncture with 3-dimensional (3D) transesophageal echocardiographic (TEE) guidance.     

Echocardiographic Guidance for Endomyocardial Biopsy

Endomyocardial biopsy is fundamental to the success of cardiac transplantation and can also provide important information for the diagnosis of primary and secondary myocardial pathology. Classically, endomyocardial biopsy procedures have utilized fluoroscopy to guide bioptome manipulation. However, echocardiographic guidance has many distinct advantages. We review our experience of 4301 echocardiography guided endomyocardial biopsy procedures. Our overall major complication rate was 0.4% with one right ventricular perforation and no procedure related mortality. These results compare favorably to traditional fluoroscopic techniques. Echocardiographic guidance for endomyocardial biopsy is safe, effective, and efficient.     

Interventional Echocardiography

Echocardiography guidance for interventions in the catheterization laboratory allows for reduction in radiation exposure from fluoroscopy as well as superior anatomic definition and visualization. The additional information provided over fluoroscopy has translated into an increasing use during interventional procedures. Procedures such as transeptal puncture, percutaneous valvular interventions, myocardial biopsy, echo-guided pericardiocentesis and other interventions have evolved to a complexity level that requires combined echocardiographic and fluoroscopic guidance. Different imaging modalities are utilized in the catheterization laboratory including intracardiac echocardiography, two-dimensional (2D) or three-dimensional (3D) transthoracic echocardiography, and 2D or 3D transesophageal echocardiography. This review is intended to provide an overall summary of the impact echocardiography has had in the catheterization laboratory. We will describe how echocardiography is utilized to guide a diverse array of interventional procedures, emphasizing specific practical issues with respect to echocardiographic guidance of interventional procedures and also pointing out the limitations of echocardiography.     

Use of echocardiography as an essential tool for targeted transcatheter biopsy of cardiac masses

Echocardiography has emerged as an essential tool to guide targeted, transcatheter biopsy of cardiac masses. Options for imaging include transthoracic or transesophageal echocardiography and intracardiac echocardiography, with appropriate use being dictated by specific patient characteristics and institutional experience. The authors present a case of three‐dimensional (3‐D) transesophageal echocardiography‐guided transcatheter biopsy of a right ventricular mass and review the current use of echocardiography to guide these procedures.     

Rapid Development of a Papillary Fibroelastoma with Associated Thrombus: The Role of Transthoracic and Transesophageal Echocardiography

Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are frequently utilized in patient's with suspected cerebral vascular ischemia. We describe a patient with suspected cerebral vascular ischemic event whom was found to have a mobile valvular mass by TTE and TEE. The lesion was unusual due to its rapid development over a period 6 months, which was documented on serial echocardiography. The mass was excised surgically and pathology showed a papillary fibroelastoma with extensive thrombus. The differential diagnosis of a cardiac valvular mass and the treatment of cardiac fibroelastomas are reviewed. In this case, both TTE and TEE were valuable in diagnosis and facilitating surgical management of a cardiac fibroelastoma.     

The diagnosis of primary cardiac lymphoma by right heart catheterization and biopsy using fluoroscopic and transthoracic echocardiographic guidance

We describe a case of primary cardiac lymphoma diagnosed by transvenous biopsy under fluoroscopic and transthoracic echocardiographic guidance. A 38-year-old man was admitted because of exertional dyspnea. ECG revealed complete atrioventricular block. Transthoracic echocardiography revealed a large mass attached to the interventricular septum and protruding into the right atrium. The patient underwent a right heart catheterization and a biopsy was taken from the mass using fluoroscopic and transthoracic echocardiographic guidance. Diagnosis of malignant lymphoma was established by the biopsy specimen. The use of transthoracic echo in conjunction with fluoroscopy may be useful for the diagnosis of intracardiac mass transvenously.     

Transesophageal echocardiography-guided transvenous endomyocardial biopsy used to diagnose primary cardiac angiosarcoma

Primary cardiac tumors are rare clinical entities with the histologic diagnosis usually made from surgically obtained tissue or at postmortem examination. Transvenous endomyocardial biopsy has been used less frequently, under fluoroscopic or transthoracic echocardiographic guidance. In this case report, we utilized the transesophageal echocardiography to guide the endomyocardial biopsy from a right atrial tumor in a 35-year-old man. © 1996 Wiley-Liss, Inc.     

Role of endomyocardial biopsy in rejection surveillance after heart transplantation in neonates and children

Objectives. The aim of this study was to retrospectively evaluate the sensitivity of noninvasive surveillance (physical examination, echocardiography) of rejection in accurately predicting histologically documented rejection episodes. Additionally, the usefulness of routine scheduled biopsy and its safety in pediatric patients was explored.Background. Endomyocardial biopsy has been utilized as the standard for rejection surveillance after heart transplantation in adults, but its role in documenting clinically suspected rejection and in routine surveillance of pediatric patients has not been agreed upon.Methods. Heart transplantation was performed in 14 neonates and 21 children. The immunosuppressive regimen consisted of cyclosporine, azathioprine and prednisone. All patients underwent routine noninvasive rejection surveillance that included clinical examination and echocardiography. In the neonates, biopsy was performed quarterly beginning 6 months after transplantation, after cessation of prednisone therapy. In the children, biopsy was performed 15 times in the 1st year. A minimum of five biopsy samples were interpreted using the Working Formulation for Heart Transplant Rejection.Results. In the neonates, 37 biopsies were performed. Evidence of rejection was present in only three biopsy samples obtained during eight episodes (38%) of clinically suspected rejection. In 29 biopsies performed when rejection was not clinically suspected, each biopsy was free of cellular infiltrate. In the children, 291 biopsies were performed. Evidence of rejection was present in only seven biopsies (41%) from 17 episodes of clinically suspected rejection. Cellular rejection was discovered during routine rejection surveillance biopsies in asymptomatic patients in 23 (8.4%) of 274 biopsies.Conclusions. In neonates with clinically suspected rejection, endomyocardial biopsy identified which patients did not require rejection therapy. Endomyocardial biopsy surveillance did not detect any unsuspected cases of rejection. In children, noninvasive rejection surveillance was less reliable even in asymptomatic patients, suggesting that periodic endomyocardial biopsy should be utilized.     

Diagnosis of a cardiac mass--a case report]

The authors describe a case of a recidivant pericardial effusion associated to a mass with an unusual, filamentous aspect that involved the upper part of right atrium and surrounded the upper vena cava. Despite the diagnostic techniques employed--transesophageal echocardiography and magnetic resonance imaging, the etiologic diagnosis could not be done, so a biopsy of the mass was made by percutaneous approach using transesophageal echocardiography to control the procedure. The histopathological result was an angiosarcoma of the right atrium. The authors make a brief review of the literature about this rare condition.     

Acute myocarditis with thrombus near left ventricular outflow tract

A young woman presented with fulminant heart failure. Transthoracic echocardiography revealed severe left ventricular dysfunction with a mass adjacent to the basal anterior wall, near the left ventricular outflow tract (LVOT). The cause of the acute heart failure and mass was unclear. Transesophageal echocardiography, with contrast, and cardiac magnetic resonance imaging findings were consistent with thrombus near the LVOT. Cardiac biopsy suggested giant cell myocarditis. The patient was treated with anticoagulation, steroids, and heart failure medications with resolution of the thrombus. This case was remarkable for the location of thrombus at the base of the ventricle.     

Cardiac angiosarcoma diagnosed by transvenous endomyocardial biopsy with the aid of transesophageal echocardiography and intra-procedural consultation

We report a case who had confirmed tumor cells in the biopsy specimens by transvenous endomyocardial biopsy with intra-procedural consultation and fast smear cytology. A 57-year-old female was admitted to our hospital because of shortness of breath and left back pain. Transthoracic echocardiography (TTE) and contrast-enhanced computed tomography (CT) scans demonstrated a large mass in the right atrium and multiple liver tumors thought to be due to spread of the disease. Coronary angiography showed the right coronary artery was involved in the mass. In order to confirm the histological diagnosis, we attempted transvenous endomyocardial tumor biopsy under fluoroscopic guidance. However, we failed to obtain adequate tissue material. Due to several risks associated with a surgical procedure such as an open surgical biopsy, transvenous endomyocardial tumor biopsy was again attempted with the aid of transesophageal echocardiography (TEE). Intra-procedural consultation and fast smear cytology enabled us to finish the procedure. Hematoxylin-eosin stained sections demonstrated spindle-shaped cells. Immunohistochemical stains of these cells were positive for anti-factor VIII antigen, CD31, and CD34. These findings indicated a definite diagnosis of angiosarcoma. Since there was no surgical indication for this tumor, the patient underwent chemotherapy with docetaxel and radiotherapy. Three months later, CT scans showed a reduction in the size of the cardiac tumor.     

Cardiac magnetic resonance imaging for non-invasive diagnosis of lipomatous hypertrophy of inter-atrial septum

A 71-year-old asymptomatic woman is found to have an incidental cardiac mass on transthoracic echocardiography. Cardiac magnetic resonance (CMR) findings are consistent with lipotamous hypertrophy of the inter-atrial septum. Given the characteristic appearances on CMR, biopsy or surgery was not indicated and the patient was managed conservatively.     

Spontaneous left atrial multiseptated intramural dissecting hematoma

Our case was initially admitted with chest discomfort and congestive heart failure with a presumptive diagnosis of non-ST segment elevation myocardial infarction and was later found to have a large left atrial (LA) mass. In addition to a complete echocardiography study, multimodality imaging was utilized to better characterize the LA mass. Despite this, the diagnosis could not be confirmed. It was decided to proceed to cardiac surgery, and surprisingly, this revealed a large LA mass with pockets of fresh blood within the LA. Pathological specimen examination confirmed a diagnosis of thrombus, effectively outruling other atrial neoplasms. Although contrast echocardiography and cardiac magnetic resonance imaging suggested this diagnosis, in the absence of any predisposing factors, the final diagnosis was made at surgery and histopathological examination.     

Right atrium mass in a 28-year-old patient with pulmonary embolism taking contraceptives

We report the case of a 28-year-old woman taking contraceptives diagnosed with pulmonary embolism with a mass in the right atrium demonstrated by trans-thoracic echocardiogram that was not recognized on a previous angio-CT. Initially, it was thought to be a thrombus, but trans-oesophageal echocardiography and cardiac MRI showed data suggestive of cardiac neoplasm. Pericardial effusion and adjacent myocardial wall thickening noted on trans-oesophageal echocardiography were reported as signs that supported the possibility of malignancy, although cardiac MRI did not show wall infiltration signs. On the contrary, it demonstrated enhancement, which excludes the thrombotic nature of the mass and supports the diagnosis of neoplasm. The patient underwent surgery and biopsy proved that the mass was a myxoma. While myxomas are the most common among primary cardiac tumors, its attachment to the atrium free wall, far from the inter-atrium septum, the bi-lobed shape and accompanying pericardial effusion were atypical.     

Invasive thymoma extending into the superior vena cava and the right atrium: a case report and review of the literature

If the neoplastic extension with the higher vena cava can be observed during the evolution of the invasive thymomes, the tumoral extension in the right auricle, remains on the other hand an exception. We report an invasive case of thymome to higher intracellar extension, right intraatrial and pleuropulmonary revealed by a syndrome undermines higher and a left pleurisy. The transthoracic echocardiography supplemented by the echocardiography transoesophageal pose the cardiac diagnosis of tumor, and it is the thoracic tomodensitometry which highlights a tumoral process mediastinal of malignant pace invading the left inominal venous trunk, the higher vena cava and extending in the right auricle. The diagnosis of certainty is carried by the endobronchial biopsy and the puncture tomodensitometric biopsy under control of the mediastinal mass after anatomopathological examination. Under chemotherapy, the evolution over 18 months is marked by the absence of cardiovascular complications in spite of the non regression of the tumoral mass. This observation stresses the importance of the realization of the echocardiography especially transoesophageal in front of all invasive thymome and the reliability of the puncture biopsy scanoguided like diagnoses technique not very invasive in the forms not extirpables. The forecast of this affection depends on the effectiveness of the processing. The surgery when it is possible, remains the principal therapeutic measurement which really proved reliable.     

Intracardiac echocardiography to guide myocardial biopsy of a primary cardiac tumour.

A 61-year-old man presented with recurrent ventricular tachycardia (left bundle branch block morphology, superior axis). Magnetic resonance imaging (Fig. 1) and contrast-enhanced transthoracic echocardiography (Fig. 2) demonstrated an ill-defined mass in the right heart along the free wall of the right atrium, involving the tricuspid valve and extending into the right ventricle. Extensive investigation showed no evidence of extra-cardiac involvement and a tissue diagnosis was recommended. Accordingly, we elected to proceed to myocardial biopsy and, to facilitate accurate tissue localisation, we performed the procedure under guidance with intracardiac echocardiography.     

Cardiac tumor biopsy under the guidance of intracardiac echocardiography

Transthoracic echocardiography or transesophageal echocardiography is sometimes useful in intracardiac tumor biopsy. Intracardiac echocardiography was used as an alternative to either of these for performing a biopsy of a right cardiac tumor in a 79-year-old woman. The procedure was well tolerated and no complications occurred. Histopathological findings and immunohistological staining were compatible with the diagnosis of neurogenic sarcoma.     

Mediastinal plasmacytoma detected by echocardiography and biopsied with EUS-FNA

Mediastinal ultrasound is currently being performed by a variety of different practioners but all need to be familiar with major pathology outside their narrow fields. We are reporting the first case where echocardiography led to the discovery of a mediastinal mass which upon endoscopic-ultrasound guided fine needle aspiration biopsy (EUS-FNA) was found to be a plasmacytoma. The differential diagnosis of mediastinal masses is briefly reviewed.     

Safety of transvenous right ventricular endomyocardial biopsy guided by two-dimensional echocardiography

A total of 231 endomyocardial biopsy procedures performed in 74 consecutive patients were evaluated to compare the incidence and nature of complications in procedures guided by fluoroscopy versus those guided by echocardiography. Sixty biopsy procedures were guided by fluoroscopy and 171 by two-dimensional echocardiography. The right interventricular septum was the target site for biopsy sampling in all patients. Clinical signs of myocardial perforation occurred during one (1.7%) procedure guided by fluoroscopy versus two (1.2%) procedures guided by echocardiography. Two cases of interventricular septal perforation were visualized during the echo-guided procedures. The biopsy specimens were judged to be inadequate for diagnosis in 2.2% of the biopsy procedures, all of which were guided by fluoroscopy. The number of samples obtained during a procedure guided by fluoroscopy was lower (mean 2.3 ± 1.6) (mean ± 1 SD) than that taken during a procedure guided by echocardiography (mean 4.0 ± 1.2). Epicardial or pericardial tissue was present in 5.8% of the samples obtained under fluoroscopic guidance, versus 0.7% of the samples obtained using echocardiography (p = 0.0003). It is concluded that although echocardiography seems to provide more accurate and safer guidance for the positioning of the bioptome toward the septum, the presence of epicardium or pericardium in 0.7% of the samples indicates that inadvertent sampling from the right ventricular free wall cannot be avoided.