Diagnosis of noninfective cardiac mass lesions by two-dimensional echocardiography. Comparison of the transthoracic and transesophageal approaches

This study was conducted in 46 patients with cardiac thrombi, 15 patients with atrial myxomas, and 32 patients with other cardiac or paracardiac tumors. Diagnoses were subsequently proven by surgery, autopsy, computed tomography, magnetic resonance imaging, or angiography in all patients. All patients underwent precordial and transesophageal two-dimensional echocardiography to assess the various mass detection rates. Atrial myxomas and predominantly left-sided cardiac tumors were identified by both echocardiographic techniques with comparable detection rates. Left ventricular apical thrombi were detected more frequently by precordial echocardiography. In contrast, transesophageal echocardiography was superior in visualizing left atrial appendage thrombi, small and flat thrombi in the left atrial cavity, thrombi and tumors in the superior vena cava, and masses attached to the right heart and the descending thoracic aorta. These data indicate that transesophageal echocardiography leads to a clinically relevant improvement of the diagnostic potential in patients in whom cardiac masses are suspected or have to be excluded in order to ensure the safety of clinical procedures.     

Cystic tumor in the left atrium: an unusual aspect of a myxoma

Most cardiac tumors are benign, whereas up to 50 % of the diagnosed cases are histologically myxomas. The common clinical signs are rhythm disturbances, myocardial ischemia, pulmonary edema, syncope and cardiac arrest. They do normally lead to the diagnostic hypothesis of an intracardiac mass. The primary modality for imaging is echocardiography which usually confirms the suspected diagnosis. But in rare cases there are masses which cannot be exactly identified by this technique. Here we present a patient with an atypical echocardiography of an unusual intracardiac tumor.     

Intracardiac floating thrombi in patients with acute pulmonary thromboembolism

The mortality and morbidity associated with residual intracardiac floating thrombi in patients with acute pulmonary thromboembolism remain uncertain. Thirteen patients (2 men and 11 women, mean age 56 +/- 15 years) with pulmonary thromboembolism underwent echocardiography within 24 hours from onset of symptoms. Four patients (31%) had floating intracardiac thrombi in the right heart: 3 in the right atrium and one in the inferior vena cava. The time to evaluation by echocardiography was shorter than in the patients without thrombi. The thrombi disappeared shortly (3.2 +/- 2.4 hr) after thrombolysis without adverse effects in these patients. After thrombolysis, clinical symptoms improved and pressure gradient between the right ventricle and right atrium decreased significantly (p < 0.01) from baseline 47 +/- 6 to 26 +/- 5 mmHg. Major bleeding complications occurred in 3 (43%) of the patients who underwent thrombolysis. Right-side intracardiac floating thrombus was easily detectable by early echocardiography. Thrombolytic agents are likely to be effective in patients with intracardiac floating thrombi.     

2-dimensional echocardiographic diagnosis of an intracardiac thrombus in children

Eight cases of intracardiac thrombi in infants and children were compiled in a cooperative study involving five paediatric cardiological centres. Two babies were hospitalised for cardiac failure due to a severe supraventricular arrhythmia. Two-dimensional echocardiography (2D echo) showed a left atrial thrombus which disappeared after anticoagulant therapy. The third case was unusual: 2D echo performed 4 months after a Senning operation for complete transposition of the great arteries showed stenosis of the pulmonary venous canal and a thrombus above the stenosis: the mass was echogenic, rounded, of variable density and in contact with the pulmonary veins. These findings were confirmed at autopsy. The fourth case was a 34 month old child with Fallot's triad in whom 2D echo showed a right ventricular thrombus, confirmed at surgery. The four remaining cases were thrombi detected in patients with congestive cardiomyopathy. The thrombus was adherent to the left ventricular lateral wall or apex. Two of these thrombi disappeared after anticoagulant therapy, one of which after hemiplegia. 2D echo is a useful tool for the diagnosis and surveillance of intraatrial or intraventricular thrombi. Intraatrial thrombi may be due to supraventricular arrhythmias in children; intraventricular thrombi are usually seen in association with poor left ventricular contractility. The diagnosis of thrombosis should lead to institution of anticoagulant or even fibrinolytic therapy in order to avoid systemic embolism.     

Should Transesophageal Echocardiography Become a Routine Test in Patients with Suspected Pulmonary Thromboembolism?

Pulmonary thromboembolism presents in two clinical subsets: acute pulmonary embolism (PE) with or without right heart thrombi or paradoxical embolism and chronic thromboembolic pulmonary hypertension (CTEPH). Both PE and CTEPH have been underdiagnosed and carry high mortality rates. Acute massive PE is a hemodynamic entity leading to right ventricular overload readily identified with the use of transthoracic echocardiography. Transesophageal echocardiography (TEE) is a noninvasive bedside technique that has high diagnostic accuracy for the detection of central pulmonary thromboembolism. Due to the high prevalence of central pulmonary thromboembolism in acute PE, TEE is a useful method to provide the necessary proof for the institution of thrombolytic therapy. In the subset of patients with acute PE combined with right heart thrombi or paradoxical embolism, TEE is the technique of choice to guide surgery. CTEPH presents as primary pulmonary hypertension, but it has become a surgically curable disease. TEE is a fast, fairly sensitive, and highly specific diagnostic bedside modality to select surgical candidates with CTEPH. TEE should become a routine test in patients with suspected massive acute PE, suspected right heart thrombi, or paradoxical embolism associated with acute pulmonary embolism and in patients with primary pulmonary hypertension to select those having CTEPH who are suitable for surgery.     

Comparison of gated cardiac magnetic resonance imaging and two-dimensional echocardiography for the evaluation of right ventricular thrombi: a case report with autopsy correlation

In a patient who died of complications of severe pulmonary hypertension, right ventricular failure, and sepsis, antemortem two-dimensional (2-D) echocardiography and magnetic resonance imaging (MRI) studies demonstrated a right ventricular mass which at autopsy proved to be thrombus. The diagnostic features of this mass as imaged by these two methods are compared. This case was complicated in that the patient had a history of right atrial myxoma that had been successfully removed three years previously, and a history of several prior pulmonary emboli. Gated MRI depicted the size, shape, and surface characteristics of the mass more clearly than 2-D echocardiography because MRI provided better contrast and spatial resolution. Both techniques were useful in localizing the mass and showing if it was fixed or mobile. Depiction of tumor attachment was unclear with echocardiography but very clear with MRI. MRI also showed a left pulmonary artery thrombus that was not visualized by 2-D echocardiography. Both techniques provided chamber dimension measurements showing enlargement of the right atrium and ventricle. This case demonstrates that gated MRI provides high-quality images of cardiac anatomy and masses. Gated cardiac MRI should be considered at least complementary and potentially superior to two-dimensional echocardiography in the evaluation of intracardiac masses in certain patients.     

Usefulness of Doppler echocardiography in the diagnosis of complications in the acute phase of myocardial infarct

Doppler echocardiography, providing objective data on heart anatomy and cardiac function, is a diagnostic method of unquestionable value in the acute phase of myocardial infarction. In what concerns myocardial infarction complications; echocardiography permits: a) evaluation of ventricular function, by quantifying heart failure and establishing the diagnosis of ventricular aneurysm; b) it is the most reliable method in the diagnosis of thrombi, and c) it constitutes a fundamental diagnostic tool in mechanical complications: rupture of the heart structures and evaluation of valvular competence. a) Evaluation of ventricular function. The analysis of ventricular dimensions and segmentary wall motion abnormalities permits the quantification of the infarct size and its repercussion upon the cardiac function. Otherwise, left ventricular proto and end diastolic filling rates give an idea about ventricular diastolic function alterations. b) Ventricular thrombi. The incidence of ventricular thrombi in AMI is variable, depending on the site of infarction and the number of segments with wall motion abnormalities. By echocardiography it has been demonstrated that 40% of the anterior transmural myocardial infarctions and 10% of the inferior ones disclosed thrombi, although the incidence of systemic embolism is scarce and similar on both anterior and inferior infarctions: nearly 2% during the first month after infarction. The criteria that identify the embolic risk include: thrombus size over 2 x 2 x 2 cm, pediculated and mobile thrombi. On the other hand, right intraventricular thrombi incidence is rare nearly 5% of right ventricular infarctions and post-infarction pulmonary embolism is probably more related to peripheral venous thrombus than to an intraventricular one. c) Mechanical complications. Echocardiography enables the direct diagnosis of interventricular septum and papillary muscles rupture in about 80% of the cases and although ordinary does not provide direct data on free ventricular wall rupture, the detection of pericardial effusion with high density echoes, together with finding of free right ventricular and atrial wall collapse, gives 80% of sensibility and over 90% of specificity in the diagnosis of free ventricular wall rupture. Finally, Doppler echocardiography permits the diagnosis and quantification of mitral and tricuspid regurgitation secondary to a rupture of even a simple disfunction of the atrioventricular subvalvular apparatus.     

Vegetative cardiac metastases of oral cavity cancer: an autopsy case report

A 60-year-old man was admitted to our hospital for evaluation of intracardiac vegetative masses detected by echocardiography in September 2001. He had undergone surgery for oral cavity cancer in 1999. He presented with severe embolic symptoms including cerebral infarction, but had few symptoms of heart failure. Antibiotic therapy was started under the diagnosis of infective endocarditis, but the embolic symptoms persisted. An autopsy revealed that the intracardiac vegetative masses consisted of tumor cells originating from the oral cavity cancer. Intravascular tumor thrombi were also found widely distributed in other organs such as the liver, lung, spleen and kidney, and had similar histological features. This is a very rare case of cardiac metastases of oral cavity cancer without adhesion to the endocardium or other myocardial tissue.     

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.     

Contrast echocardiography as a useful additional diagnostic tool in evaluating a primary cardiac tumor.

The current report describes a case of a primary cardiac lymphoma. For early and appropriate treatment of a cardiac mass it is not only important to determine its localization and extension but also to differentiate between malignant and benign lesions. This report demonstrates that not only transthoracic echocardiography but also the other different forms of echocardiography such as transesophageal echocardiography, as well as contrast and intracardiac echocardiography, are useful tools in the diagnostic workup of cardiac masses.     

Magnetic resonance imaging of cardiac masses

INTRODUCTION: Cardiac magnetic resonance imaging plays a pivotal role in the diagnostic workup of cardiac masses. In many cases it is possible to arrive at a likely diagnosis, while features suggestive of a conclusive diagnosis are detected in a small number of cases. METHODS: An internal audit of all patients referred with a cardiac mass detected on echocardiography was conducted for the period 2004-2007. Twenty-two cases were identified and MR characteristics including localization, tissue characteristics, primary nature versus secondary deposits and extracardiac features were studied. RESULTS: Six masses were intramyocardial, eleven were intracavitary and three were extraeardiac in localization. A highly probable diagnosis was possible in fourteen cases including six primary tumors, three extracardiac tumors, three secondary deposits and two thrombi. ConclusioN: A highly probable diagnosis was possible in half of our patients with cardiac masses on echocardiography referred for cardiac magnetic resonance imaging in the p receding three-year period. It was also possible to determine localization, extent of disease and relation to adjacent structures.     

Multiple intracavitary cardiac masses; an uncommon presentation of African Burkitt's lymphoma.

A 29-yr-old patient is described, who presented with rapid general deterioration and right heart failure. Two-dimensional echocardiography revealed massive intracardiac tumor involving the right atrium, the right ventricle and the left atrium. At histology the diagnosis of Burkitt's lymphoma was made. This report presents what we believe to be the first case of a patient with primary cardiac manifestations and multiple intracardiac masses in this disease.     

Acute kidney infarction secondary to intracardiac thrombus embolization in a patient with ischemic dilated cardiomyopathy

Acute renal infarction due to emboli represents a very rare but significant threat for kidney loss, and the clinical presentation is challenging. The differential diagnosis of massive renal thrombi includes all other causes of abdominal pain, and they can be easily misdiagnosed as renal colic due to nephrolithiasis. Although there are a few case reports regarding the possibility that cardiac emboli may cause acute kidney infarction, intracardiac thrombi within the ventricular cavity diagnosed by echocardiography as a cause of such renal artery occlusion have never been reported in patients with cardiomyopathy. Herein, we describe a 39-year-old male with a history of ischemic dilated cardiomyopathy. He was admitted to our hospital with left upper abdominal pain and vomiting. After serial examinations and tests, the diagnosis of acute renal infarction due to intracardiac thrombus embolization as a result of severely reduced cardiac function was made.     

Cardiac metastasis from colorectal cancer： A case report

The heart is an unusual site of metastasis from any malignancy. We report a case of cardiac metastasis from colorectal cancer. A 70-year-old woman was referred with a presumptive diagnosis of sigmoid colon cancer with cardiac myxoma. Two-dimensional echocardiography showed a 4 cm x 4.5 cm mobile mass on the lateral right atrial wall, and computed tomography revealed a low attenuated Iobulating mass in the right atrium. The patient underwent anterior resection for sigmoid colon cancer （T4N2）. Thereafter, she experienced progressive shortness of breath. Therefore, a cardiac operation was performed 2 wk after the colorectal operation. Histological examination revealed adenocarcinoma, which was identical to the primary lesion. Although two- dimensional echocardiography has become the diagnostic test of choice for detecting cardiac tumors, in patients with colorectal cancer showing a cardiac mass, further diagnostic evaluation such as a magnetic resonance imaging might be necessary.     

Intracardiac thrombi in primary antiphospholipid syndrome: two case reports

We describe two patients who developed stroke and ischemia of the left lower limb, related to intracardiac thrombi, as the first manifestation of primary antiphospholipid syndrome (PAPS). Transesophageal echocardiography (TEE) revealed intracardiac thrombi as abnormal hyperechogenic, nonmobile masses, firmly attached to the left atrial appendage and the anterior part of the mitral annulus, respectively. Our patients received high-intensity oral anticoagulant therapy (INR 3.0–4.0), which resulted in the rapid disappearance of clinical symptoms, without subsequent recurrence of thromboembolic manifestations, and the disappearance of intracardiac thrombi on TEE. Our findings underscore that PAPS should be suspected in patients presenting with intracardiac thrombi, even if they have no previous history of thromboembolic disorders. Moreover, because intracardiac thrombi may precede other manifestations of PAPS, this finding in young patients without underlying heart disease should invoke a search for both antiphospholipid and anticardiolipin antibodies.     

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.     

Papillary fibroelastoma of the pulmonary valve: assessment by live/real time three-dimensional transthoracic echocardiography

The differential diagnosis of a cardiac valve mass includes fibroelastoma, myxoma, lipoma, Lambl's excrescences, thrombus, and vegetation. Fibroelastomas are extremely rare primary cardiac tumors. Their incidence is 0.00017-0.033% in autopsy series and 0.019% in clinical series identified on echocardiography. Although rare, fibroelastomas are the most common tumors affecting the cardiac valves with aortic, mitral, tricuspid, and pulmonary valves being involved in this order. In the current report we describe a case of pulmonary valve mass in which a confident prospective diagnosis of fibroelastoma could be made utilizing the technique of three-dimensional transthoracic echocardiography.     

Left ventricular thrombi: In vivo detection by indium-111 platelet imaging and two dimensional echocardiography

Indium-111 platelet Imaging, which can Identify sites of active intravascular platelet deposition, and two dimensional echocardlography, which can identify intracardiac masses, can both be used to detect left ventricular thrombi noninvasively. We compared these techniques in 44 men at risk for thrombi from remote transmural myocardial infarction (31 patients) or cardiomyopathy (13 patients). All 44 patients underwent platelet imaging; 35 underwent echocardlography.On platelet imaging nine patients had thrombi and one had a possible thrombus. Of these 10 studies, none were positive at 2 hours, 5 were positive at 24 hours and all were positive 48 or 72 hours after platelet labeling. Nine of these patients underwent echocardlography, and all had an intraventricular mass. The findings on platelet scanning were negative in six patients who had positive (four patients) or equivocally positive (two patients) findings on echocardiography. All patients with thrombi detected by either noninvasive method had transmural anterior myocardial infarction with ventricular aneurysm. Of the seven patients who underwent cardiac surgery or autopsy, three had thrombi. Platelet imaging failed to Identify one thrombus in a patient in whom imaging was performed only at 24 hours after labeling. There were no false positive platelet images in this group. Five of these seven patients (two with thrombi, three without) underwent echocardiography; in all cases the echocardiographic findings agreed with the pathologic findings.Both platelet Imaging and echocardiography detect ventricular thrombi. Platelet imaging may detect only the most hematologically active thrombi. Both techniques may help define patients at risk of embolization and may be useful for in vivo assessment of antithrombotic drugs.