Intra-cardiac Masses and Devices

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Intra-cardiac Masses and Devices

Al Solina, F. Luke Aldo and Salvatore Zisa

Cardiac Masses: A mass by any other name, is still a mass. Or is it?

You may remember from high school physics that mass is simply a quantity of matter. Under the right set of circumstances, it can even be converted into a predictable amount of energy. But that’s not what we are talking about here. Cardiac masses come in a variety of shapes, sizes, locations, consistencies, and clinical significance. They can be characterized primarily into real masses, and normal anatomical structures that masquerade as masses. Real cardiac masses can be further characterized as being benign or malignant, and as being primary or metastatic. In order to differentiate between these possibilities it is important to understand normal anatomy, the physics involved with imaging artifacts (see Chapter 5), and the characterization of real cardiac masses. Echocardiography has been utilized to image cardiac masses since the 1950s, and can be used to characterize the anatomy and pathophysiological consequences of the mass. Although a mass may be histologically benign, it may muck up the normal function of the heart by interfering with chamber filling or valve function, and therefore not be benign from a physiological perspective.

Masses that are Not Really Masses

Normal anatomic variants: these structures, although normal anatomic features, may mimic cardiac masses.

Atrial Anatomic Variants

image Chiari network—having little to do with communications or information technology, this network is a filamentous embryological remnant located in the RA.

image Coumadin ridge—a finger-like projection of tissue in the LA, which separates the left superior pulmonary vein from the left atrial appendage. It is sometimes mistaken for a thrombus.

image Crista terminalis—not a train station in Rome, but rather a ridge of tissue in the RA located at the junction of the SVC and the RA appendage.

image Eustachian valve—an embryological remnant, located at the junction between the IVC and the RA, and directed towards the fossa ovalis of the interatrial septum.

image Foreign bodies—pacemaker and AICD leads, catheters, and cannulae of all different flavors may parade around in the atria. Additionally they may cause reverberations and side lobe artifacts that further muddle things up.

image Lipomatous hypertrophy of the interatrial septum—this benign variant is characterized by a sometimes dramatic thickening of adipose tissue surrounding, but sparing the fossa ovalis of the interatrial septum. It kind of looks like a dumbbell. Thick-thin-thick. While not having any meaningful significance in terms of acute pathophysiological consequence, it is easy to recognize and very impressive to say.

image Pectinate muscles—line the RA in a perpendicular array.

Masses that Really are Masses

“Benign” primary cardiac masses: these masses are “benign” in their tissue characterization, but may misbehave and cause functional disturbances attributable to their anatomical location!

image Myxoma—most common primary tumor, seen most frequently in the LA. Can be quite large and interfere with valvular function. Have a non-homogeneous appearance. Female preponderance. May commonly be seen attached to a stalk from the LA side of the interatrial septum. May be associated with systemic embolization.

image Lipoma—second most common benign primary cardiac mass. Usually found in the left ventricle and right atrium, are homogeneous and hyperechoic in appearance. Not associated with systemic embolization. Can be up to 15 cm in size.

image Fibroma—second most common benign cardiac tumor in children (rhabdomyoma is first). Most frequently seen in the ventricle. Although benign in tissue type, may be associated with impaired ventricular filling and/or arrythmias.

image Vegetation—strange name really. Don’t think anyone really considers these little nuggets to be edible. Bacteremic vegetations are usually found in the left heart (except in the case of IV drug abusers), and are usually located on the upstream side of the valve. They can interfere with valve function and may be associated with abcesses. Movement usually synchronized with valve motion as they are attached to it.

image Papillary fibroelastoma—as the most common primary tumor affecting valves, it resembles a small (<1 cm) vegetation, but is usually seen on the downstream side of a valve. Found more frequently in association with left heart valves in patients greater than 50 years of age. Are sometimes associated with embolic events.

image Rhabdomyoma—most common tumor in children, usually before one year of age. May obstruct blood flow and can be associated with arrhythmias and heart block. Frequently found in conjunction with tuberous sclerosis.

image Thrombi—tend to occur in areas of slow blood flow such as the left atrial appendage, LV apex, and ventricular aneurysms. One hint that the blood is slow-moving is when you see slowly swirling streams of blood movement, called “smoke”. Where there is smoke there are thrombi! Thrombi are readily detected in the LA by TEE, but may be more difficult to interrogate and define when they reside in the ventricular apex.

Schematic Representation of Common Cardiac “Masses”

image

Questions

1. Which is the most common primary malignant cardiac tumor in children?

2. The most common primary tumor affecting valves is:

3. A filamentous embryological remnant located in the RA

4. Which of the following is/are true regarding angiosarcoma?

5. Which of the following statements is/are true?

6. Which of the following is/are true?

7. Which is are true regarding papillary fibroelastoma?

8. Which is/are true of fibromas?

9. Which is/are true regarding lipomas?

10. Which is/are true regarding thrombi?

Answers

Bibliography

Armstrong W, Ryan T. Masses, tumors, and source of embolus. In Feigenbaum’s “Echocardiography”, 7th Edition, Chapter 23, Lippincott Williams and Wilkins, 2010.

Hari P, Mohamad T, Kondur A, et al. Incremental value of contrast echocardiography in the diagnosis of atrial mxyoma. Echocardiography. 2010;27(5):E46–E49.

Kirkpatrick J, Wong T, Bednarz J, et al. Differential diagnosis of cardiac masses using contrast echocardiographic perfusion imaging. J Am Coll Cardiol. 2004;43(8):1412–1419.

Muller S, Feuchtner G, Bonatti J, et al. Value of transesophageal 3D echocardiography as an adjunct to conventional 2D imaging in preoperative evaluation of cardiac masses. Echocardiography. 2008;25(6):624–631.

Peters P, Reinhardt S. The echocardiographic evaluation of intracardiac masses; a review. J Am Soc Echocardiography. 2006;19(2):230–240.

Ragland M, Tahir T. The role of echocardiography in diagnosing space-occupying lesions of the heart. Clinical Medicine and Research. 2006;4(1):22–32.

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