Right-sided cardiac tumors detected by transesophageal echocardiography and its usefulness in differentiating the benign from the malignant ones

Percutaneous intravenous catheter forceps biopsy in right atrial mass: two case reports and literature review

Background

Primary malignant tumors of the heart are rare. Although preoperative histological diagnosis is difficult, it has paramount value in therapeutic strategy development and prognostic estimation. Herein, we reported 2 cases of intracardiac tumors.

Cases presentation

Both patients presented to the hospital with heart-related symptoms. Echocardiography showed massive masses in the atrium and positron emission tomography–computed tomography (PET/CT) revealed hypermetabolism and invasiveness. One patient cannot take surgery due to extensive metastasis and poor condition. The other patient was primarily diagnosed with lymphoma, and surgery was not recommended. They successfully underwent intravenous atrial biopsy, and histological samples confirmed intimal sarcoma and diffuse large B cell lymphoma. Based on immunohistochemical and molecular assessments, targeted chemotherapy was administered, resulting in clinical and imaging remission at discharge.

Conclusions

Percutaneous intravenous catheter biopsy as a safe invasive test provides an accurate pathological diagnosis after imaging evaluation, and offers a therapeutic direction. Nonmalignant masses and some chemo-radiosensitive malignant tumors in the atrium could have good prognosis after targeted therapy.

The value of multimodality imaging in diagnosis and treatment of cardiac lipoma

Background

Cardiac lipoma is a rare primary tumor in the heart and pericardium. Multimodality imaging methods, especially magnetic resonance imaging (MRI), are crucial in detecting and diagnosing cardiac lipomas. Besides, they are of significant importance in management of cardiac lipomas. The aim of this study was to evaluate the value of multimodality imaging methods in diagnosing and treatment of cardiac lipoma by describing a series of cases of cardiac lipoma.

Materials and methods

Data of patients with cardiac lipoma at a local institution were retrospectively collected. Their imaging findings on echocardiography, computed tomography (CT), and cardiac MRI and clinical management were described in detail.

Results

12 patients with cardiac lipoma were retrospectively included with thirteen lipomas found within heart and pericardium. Two patients’ lipoma were symptomatic, while lipomas in other 10 patients were found incidentally. Most lipomas were sensitively detected with echocardiography. Accurate diagnoses were achieved with CT and MRI in all cases. Surgical resection was performed in one symptomatic patient due to the obstruction of the left ventricular outflow tract, while the removal of pericardial lipoma in another symptomatic patient was not possible due to diffuse myocardial infiltration observed in MRI. Based on MRI findings, two patients without clinical symptoms also underwent surgery to prevent the risk of detachment of ventricular lipoma with a narrow pedicle in one patient and potential further thinning of the myocardium by pericardial lipoma growth in another patient.

Conclusions

Cardiac lipoma could be sensitively detected and accurately diagnosed with multiple noninvasive imaging tools. Comprehensive evaluation with multimodality imaging methods should also be conducted for better management planning and follow-up in all patients.

Primary Cardiac Osteosarcoma

BACKGROUND

Primary cardiac osteosarcoma is extremely rare. There is no cohort study on such tumours to date. The aim of this study is to investigate the clinical characteristics and outcome patterns of such tumours.

METHODS

A thorough literature review was performed, and all relevant clinical items were collected. A total of 53 cases of primary cardiac osteosarcoma were enrolled in this study, including 25 males and 28 females.

RESULTS

The age at diagnosis ranged from 14 to 77 years with a mean age of 43.6 years. The clinical manifestations, imaging features, and laboratory tests of the primary cardiac osteosarcomas were similar to other types of primary cardiac tumours. Sex, tumour size and adjunctive chemo-radiotherapy were found to affect the overall survival pattern.

CONCLUSIONS

The present study may provide an effective consultation for the diagnosis and treatment of this tumour.

Infiltrating Lipoma of the Right Ventricle Involving the Interventricular Septum and Tricuspid Valve: Report of a Rare Case and Literature Review

Cardiac lipoma, which are primary cardiac tumors, are rare entities often detected incidentally during imaging. There have been very few reports on the right ventricle (RV) lipoma. Here, we present a case of RV infiltrating lipoma involving the interventricular septum (IVS) and the tricuspid valve. Clinical symptoms, diagnostic procedures, multimodality imaging characteristics, and treatment are discussed, and the complete clinical data of this case and relevant details of retrospective literature are reviewed. The study described the case of a 48-year-old woman who suffered from occasional palpitation after exertion for 10 years. Imaging examinations, including echocardiography and cardiovascular magnetic resonance imaging (MRI), revealed a large mass adherent to the IVS and the right ventricular wall that was consistent with lipoma. The patient underwent surgical repair of the tricuspid valve and excision of the partial mass. The gross specimen revealed piles of 5 × 4 × 3 cm fragments with yellowish appearance and pathological results showed infiltrating lipoma.Lipoma is often asymptomatic and diagnosed incidentally. Surgical excision is the main therapeutic intervention, which is always performed in cases of symptomatic lipoma or when malignancy is suspected. Multimodality imaging would be great help in the diagnosis of cardiac lipoma. Echocardiography is a convenient method for follow-up.

Primary cardiac leiomyosarcoma: an analysis of clinical characteristics and outcome patterns

BACKGROUND

Primary cardiac leiomyosarcoma is an extremely rare entity. There is no accumulated knowledge about the clinical characteristics and therapeutic strategies for this tumor. This study aimed to systematically review the available literature to investigate the clinicoradiologic and clinicopathologic characteristics, treatment, and outcomes in patients with primary cardiac leiomyosarcoma.

METHODS

We identified 79 instances derived from 72 unique reports and carefully analyzed all clinical presentations, imaging, pathology, treatments, and outcomes.

RESULTS

The mean age at onset was 48 years. A symptom of obstruction was the most frequent complaint at diagnosis. Routine imaging methods such as echocardiography, computed tomography, and magnetic resonance imaging had high sensitivity in diagnosis. The tumor has a poorer life expectancy than its counterparts in other sites. The 5-year overall survival and recurrence-free survival rates were 25.4% and 14.7%, respectively. Overall survival was affected by age, surgery, and adjunctive chemotherapy or radiotherapy.

CONCLUSIONS

Our findings suggest that primary cardiac leiomyosarcomas tend to be biologically more aggressive compared to their counterparts in other sites. However, complete resection and adjunctive chemotherapy or radiotherapy may help to increase the life expectancy.

A right atrial mass, patent foramen ovale, and indwelling central venous catheter in a patient with a malignancy: a diagnostic and therapeutic dilemma

A 33-year-old woman with a history of gestational trophoblastic disease presented for investigation of a right atrial mass. She had been receiving chemotherapy administered via a Port-a-Cath system for 2 months prior to presentation. On transesophageal echocardiography and magnetic resonance imaging, she was found to have a mass attached to the right atrial free wall, with a segment projecting across a patent foramen ovale. Because of the risk for an embolic event, the mass was surgically removed and the patent foramen ovale repaired. Pathology showed an organized thrombus. This case emphasizes the need for high suspicion for thrombus when a right atrial mass is found in a patient with a hypercoagulable state due to underlying malignancy who has a central venous catheter.

American Society of Echocardiography Consensus Statement on the Clinical Applications of Ultrasonic Contrast Agents in Echocardiography

ACCREDITATION STATEMENT: The American Society of Echocardiography (ASE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The ASE designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit.trade mark Physicians should only claim credit commensurate with the extent of their participation in the activity. The American Registry of Diagnostic Medical Sonographers and Cardiovascular Credentialing International recognize the ASE's certificates and have agreed to honor the credit hours toward their registry requirements for sonographers. The ASE is committed to resolving all conflict-of-interest issues, and its mandate is to retain only those speakers with financial interests that can be reconciled with the goals and educational integrity of the educational program. Disclosure of faculty and commercial support sponsor relationships, if any, have been indicated.

TARGET AUDIENCE

This activity is designed for all cardiovascular physicians, cardiac sonographers, and nurses with a primary interest and knowledge base in the field of echocardiography; in addition, residents, researchers, clinicians, sonographers, and other medical professionals having a specific interest in contrast echocardiography may be included.

OBJECTIVES

Upon completing this activity, participants will be able to: 1. Demonstrate an increased knowledge of the applications for contrast echocardiography and their impact on cardiac diagnosis. 2. Differentiate the available ultrasound contrast agents and ultrasound equipment imaging features to optimize their use. 3. Recognize the indications, benefits, and safety of ultrasound contrast agents, acknowledging the recent labeling changes by the US Food and Drug Administration (FDA) regarding contrast agent use and safety information. 4. Identify specific patient populations that represent potential candidates for the use of contrast agents, to enable cost-effective clinical diagnosis. 5. Incorporate effective teamwork strategies for the implementation of contrast agents in the echocardiography laboratory and establish guidelines for contrast use. 6. Use contrast enhancement for endocardial border delineation and left ventricular opacification in rest and stress echocardiography and unique patient care environments in which echocardiographic image acquisition is frequently challenging, including intensive care units (ICUs) and emergency departments. 7. Effectively use contrast echocardiography for the diagnosis of intracardiac and extracardiac abnormalities, including the identification of complications of acute myocardial infarction. 8. Assess the common pitfalls in contrast imaging and use stepwise, guideline-based contrast equipment setup and contrast agent administration techniques to optimize image acquisition.

A right atrial hemangioma mimicking thrombus in a patient with atrial arrhythmias

Cardiac hemangiomas are rare tumors, accounting for only 2.8% of all benign primary cardiac tumors and occur at any age. Clinical presentations vary depending on the tumor location (myocardial, endocardial or pericardial). In many cases, this may be an incidental finding. We report the case of a patient with paroxysmal atrial fibrillation who had a right atrial hemangioma detected with transesophageal echocardiography prior to having percutaneous pulmonary vein isolation performed.

Pulmonary Stenosis due to Right Ventricular Outflow Tract Metastasis from a Uterine Sarcoma

A 50 year-old woman presented with dyspnoea and symptoms and signs of systemic venous congestion. Examination revealed murmur of pulmonary stenosis. Echo-Doppler, CT scanning and Magnetic Resonance Imaging showed a large right ventricular tumour obstructing the right ventricular outflow tract. She had a hysterectomy for menorrhagia 9 years previously, and resection of a lump involving the right trapezius a month prior to her deterioration. Pathology demonstrated low-grade endometrial stromal sarcoma. She deteriorated acutely in hospital due to pulmonary embolism from superimposed thrombosis. Anticoagulation, followed by radiotherapy resulted in marked clinical improvement. Two years later, the patient remains well. Cardiac metastasis from ESS is rare. Diagnosis is established by echocardiography, CT and cardiac MRI, which allow structural and functional evaluation of the tumour. MRI seems to be the most useful modality. Treatment is palliative or curative resection. This is the first case report of cardiac ESS showing good response and prolonged survival after radiotherapy. Prophylactic anticoagulation should be considered as pulmonary embolism can cause marked deterioration.

Piercing-related endocarditis presenting with multiple large masses in the right-side chamber of the heart

We present a case report of a 15-year-old girl with right-side endocarditis, which presented with multiple large masses located on both right chambers mimicking the appearance of a tumor. There were no predisposing factors other than an infected navel piercing. Piercing-associated infective endocarditis has occasionally been reported, and usually occurs in patients with an underlying cardiac condition. We briefly discuss the main features of piercing-related endocarditis and also some aspects of cardiac tumors as differential diagnosis of large cardiac masses.

Acute myocardial infarction caused by paradoxical tumorous embolism as a manifestation of hepatocarcinoma

A 71 year old patient presented with a non-ST segment elevation acute myocardial infarction. The echocardiogram showed several masses attached to the interatrial septum. Several days after admission the patient died. A postmortem examination found a large hepatocarcinoma with intravascular and intracardiac metastases and several myocardial infarctions of different ages. The infarctions had been caused by coronary paradoxical embolisms through a patent foramen ovale and contained neoplastic cells from the liver carcinoma, which had not been diagnosed. The cause of death was a massive pulmonary embolism.

Differential diagnosis of cardiac masses using contrast echocardiographic perfusion imaging

OBJECTIVES

We investigated the usefulness of echocardiographic contrast perfusion imaging in differentiating cardiac masses.

BACKGROUND

Two-dimensional echocardiography is the primary diagnostic modality for cardiac masses. However, differentiation between the different types of cardiac masses may be difficult at times. We hypothesized that echocardiographic contrast perfusion imaging would differentiate the neo-vascularization of malignancies from the avascularity of thrombi and the sparse vascularity of stromal tumors.

METHODS

Sixteen patients with cardiac masses underwent power-modulation imaging after echocardiographic intravenous contrast administration. Pixel intensities in the mass and an adjacent section of myocardium were analyzed visually and by dedicated software. All masses had a pathologic diagnosis or resolved after anticoagulation. In a subset of patients, video-intensity curves of contrast replenishment in the mass and myocardium over time were generated. The post-impulse steady-state pixel intensity (A) and initial rate of contrast replenishment after impulse (beta) were compared with an index of blood vessel area on pathology.

RESULTS

In seven of 16 patients, contrast enhancement resulted in greater pixel intensity in the mass than in the adjacent myocardium. All of these masses were classified pathologically as malignant (n = 6) or benign and vascular (n = 1). Nine masses demonstrated decreased pixel intensity, compared with the myocardium, and were diagnosed pathologically as myxomas (n = 2) or thrombi (n = 5), or they resolved with anticoagulation (n = 2). For the subset of patients, beta correlated with the vessel area index (r = 0.60).

CONCLUSIONS

Echocardiographic contrast perfusion imaging aids in the differentiation of cardiac masses. Compared with the adjacent myocardium, malignant and vascular tumors hyper-enhanced, whereas stromal tumors and thrombi hypo-enhanced.

Les sarcomes primitifs du cœur : revue de la littérature, illustrée par 3 cas

Primary cardiac sarcoma is a rare tumor with a poor prognosis. We report 3 cases with a review of literature about this disease. There were 2 males and 1 woman. The main symptoms were thoracic pain. The clinical features were various and the thoracic ultra sonography exam allowed the diagnosis in the 3 cases. All patients had surgical remove of their cardiac tumor followed by chemotherapy. All of them died within 13 to 36 months after the diagnosis. Primary cardiac sarcoma has a poor prognosis with a mean survival less than 12 months.

Usefulness of magnetic resonance imaging of cardiac and paracardiac masses

In this study, magnetic resonance imaging was compared with histology to evaluate the usefulness of magnetic resonance imaging to distinguish malignant from benign cardiac and paracardiac masses in 55 patients. Tumor location, tissue composition, and pericardial or pleural effusion all were identified as key predictors of lesion type. Observers were accurate in the prediction of lesion type (area under curve 0.88 and 0.92), and there was good interobserver variability (Cohen's kappa = 0.64).

A rare localization in right-sided endocarditis diagnosed by echocardiography: a case report

BACKGROUND

Right-sided endocarditis occurs predominantly in intravenous drug users, patients with pacemakers or central venous lines and with congenital heart diseases. The vast majority of cases involve the tricuspid valve.

CASE PRESENTATION

A case of a 31-year-old woman with intravenous drug abuse who had a right-sided vegetation attached to the muscular bundle of the right ventricle is presented. Transthoracic echocardiography revealed a vegetation in the right ventricular outflow tract. Transesophageal echocardiography clearly showed that the 1.8 cm vegetation was not adherent to the pulmonary valve but attached to a muscular bundle.

CONCLUSIONS

Our case points to an unusual location of right-sided endocarditis in intravenous drug users. It confirms that TTE remains an easy and highly sensitive first-line examination for the diagnosis of right-sided endocarditis.

Urgent heart surgery for an atrial mass: metastatic hepatocellular carcinoma

Extension of metastatic hepatocellular carcinoma into the right atrium is exceedingly rare and has a very poor prognosis. We report a case of successful surgical excision of hepatic tumor extension into the right atrium that was causing hemodynamic compromise.

Leiomyosarcoma of the right ventricle extending into the pulmonary trunk

Primary leiomyosarcomas of the heart, particularly those affecting the right ventricle, are uncommon. A 70 year old woman presenting with the symptoms of progressive exertional dyspnoea and left sided pleuritic pain is presented. A leiomyosarcoma was diagnosed that originated in the right lateral ventricle wall, causing pulmonary outflow obstruction. Pathological analysis showed a neoplasm with a myxoid stroma, high mitotic activity, and nuclei expressing atypia. Immunohistochemical staining was found positive for vimentin and desmin. Seven months after complete surgical resection the tumour relapsed. This case illustrates the poor outcome, high relapse rate, and inefficiency of treatment associated with primary cardiac leiomyosarcomas. The current literature regarding incidence, diagnostic techniques, treatment strategies, and survival rates of this rare but terminal disease is reviewed.

Leiomyosarcoma of the right ventricle extending into the pulmonary trunk

Primary leiomyosarcomas of the heart, particularly those affecting the right ventricle, are uncommon. A 70 year old woman presenting with the symptoms of progressive exertional dyspnoea and left sided pleuritic pain is presented. A leiomyosarcoma was diagnosed that originated in the right lateral ventricle wall, causing pulmonary outflow obstruction. Pathological analysis showed a neoplasm with a myxoid stroma, high mitotic activity, and nuclei expressing atypia. Immunohistochemical staining was found positive for vimentin and desmin. Seven months after complete surgical resection the tumour relapsed. This case illustrates the poor outcome, high relapse rate, and inefficiency of treatment associated with primary cardiac leiomyosarcomas. The current literature regarding incidence, diagnostic techniques, treatment strategies, and survival rates of this rare but terminal disease is reviewed.

Ventricular outflow tract obstruction secondary to leiomyosarcoma of the right ventricle

Primary leiomyosarcomas of the heart, particularly those affecting the right ventricle, are uncommon. We report the case of a 70-year-old Belgian woman presenting with the symptoms of progressive exertional dyspnea and left-sided pleuritic pain. A leiomyosarcoma which originated from the right lateral ventricle wall, causing pulmonary outflow obstruction, was diagnosed. Pathology revealed a neoplasm with a myxoid stroma, high mitotic activity and nuclei expressing atypia. Immunohistochemical staining was positive for vimentine and desmin. Seven months after complete surgical resection the tumor relapsed. This case demonstrates the poor outcome, the high relapse rate and inefficiency of treatment associated with primary cardiac leiomyosarcomas. The current literature regarding the incidence, diagnostic techniques, treatment strategies and survival rates of this rare but terminal disease is reviewed.

Left atrial invasion by lung carcinoma through a pulmonary vein

We describe a rare case of small-cell lung carcinoma invading the left atrium through a pulmonary vein. Echocardiography was particularly useful in this case in assessing the intracavitary extension of the tumor and the outcome of therapy. Echocardiography is a low-cost, easy imaging tool, complementary to radiological techniques and useful in evaluating thoracic tumors involving the cardiovascular structures.

[Large myxoma of the right atrium]

We describe the case of a patient in whom two-dimensional echocardiography, performed due to dissociated cholestasis and jugular ingurgitation, demonstrated a huge mass in the right atrium which prolapsed in the right ventricle. Intraoperative transesophageal echocardiography was performed to further assess the dimension and characteristics of the mass and to discard the involvement of associated structures. The patient underwent a cardiopulmonary bypass surgery and the mass (12 * 5 cm) was removed without complications. Histologic examination confirmed the diagnosis of myxoma. This case is of interest because of the size of the mass, and is centered in the diagnosis following clinical suspicion due to the pattern of dissociated cholestasis and jugular ingurgitation leading to surgery to prevent the potential embolic complications.

Primary cardiac lymphoma diagnosed by percutaneous intracardiac biopsy with combined fluoroscopic and transesophageal echocardiographic imaging

Primary cardiac tumors have very low prevalence with cardiac lymphoma, being one of the rarest forms. Several recent reports have shown transesophageal echocardiography to be an accurate technique for characterizing and localizing these neoplasms, with results comparable to CT and MRI scans. Transvenous intracardiac tumor biopsy has been employed as a minimally invasive technique to obtain tissue samples. The addition of transesophageal echocardiographic (TEE) guidance to this process has increased the accuracy of obtaining diagnostic specimens while improving patient safety. We review published cases of this relatively new technique using combined fluoroscopic and TEE guidance and present a case of primary cardiac lymphoma diagnosed by this method. The patient achieved complete tumor remission after treatment with standard chemotherapy and remains fully functional 32 months after initial diagnosis.

Asymptomatic right atrial leiomyosarcoma with tricuspid valve obstruction in a young female patient

Primary cardiac leiomyosarcomas of the heart are rare tumors usually diagnosed post-mortem. Like other sarcomas located in the heart, it causes symptoms by obstruction or occlusion of cardiac cavities, local invasion, embolization or by systemic manifestations. We present an unusual case of a previously healthy young female patient who was accidentally diagnosed with a cardiac tumor of unknown origin during routine physical examination in May 1997. Until a few days prior to elective cardiac surgery for diagnostic purposes in June 1997, no clinical symptoms were present. To our surprise, a primary right atrial leiomyosarcoma was found which almost completely occluded the right atrium and destroyed the tricuspid valve. Despite the combination of surgical removal and adjuvant chemotherapy the patient died 3 weeks after the operation due to progressive tumor disease and development of congestive heart failure and lung embolism.

Left atrial leiomyosarcoma: double occurrence and double recurrence--report of one case

In October 1996 a 67-year-old man underwent transthoracic and transesophageal echocardiography (TEE) because of dyspnea on exertion and was found to have 2 left atrial cardiac masses. The 2 masses were surgically removed from the atrium and showed histopathologic and ultrastructural features of a leiomyosarcoma. Seven months later a double recurrence of left atrial masses was found with TEE; the patient refused surgery and decided instead to receive chemotherapy. In May 1998 he was in stable condition (New York Heart Association class III), but a further growth of the 2 left atrial masses was observed at TEE. We describe the echocardiographic features of the 2 cardiac masses and the clinical and prognostic implications.