Cardiovascular magnetic resonance imaging for assessment of cardiac thrombus

Central venous catheter-related right atrial thrombus in oncology patients: a case series of cardiovascular magnetic resonance studies

Background

Patients with cancer are at an increased risk of thrombus formation, often identified on routine echocardiogram in the right atrium. The 2022 ESC Guidelines on Cardio-oncology emphasize cardiac magnetic resonance (CMR) as the gold standard for thrombus identification.

Case summary

We present a case series of seven patients who underwent CMR due to right atrial mass suspected to result from central venous catheter-related right atrial thrombus. In all cases, CMR enabled accurate diagnosis of a thrombus. It also allowed to assess complete or partial resolution of the thrombi following anticoagulation on follow-up studies.

Discussion

The presence of a central venous catheter is recognized as a risk factor for thrombus formation, particularly when inappropriately advanced into the right atrium. The integration of CMR into the diagnostic pathway enabled precise thrombus identification and guidance for treatment in this population with a complex balance between cancer-related thrombotic and haemorrhagic risks.

Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review

Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.

Incidentally Discovered Right Atrial Mass: A Rare and Unexpected Etiology

Primary cardiac sarcoma is a rare type of intracardiac mass. This report describes a patient with atrial flutter who had a new right atrial mass incidentally discovered on transesophageal echocardiography. A thrombus was suspected based on radiographic appearance, but there was minimal change with anticoagulation. The mass was resected and found to be an undifferentiated pleomorphic cardiac sarcoma, an uncommon sub-type within the already rare category of primary cardiac neoplasms. This report highlights the importance of considering primary malignancy and thoroughly correlating radiographic and clinical evidence during the diagnostic workup of patients with intracardiac masses.

Risk factors for in-hospital systemic thromboembolism in myocardial infarction patients with left-ventricular thrombus: A multicenter retrospective study

Left-ventricular thrombus (LVT) is a potentially life-threatening disease. However, few studies have explored the risk factors of in-hospital systemic thromboembolism (ST) in LVT patients. In this multicenter retrospective study, we enrolled myocardial infarction patients with LVT from January 2008 to September 2021. Multivariable logistic regression analysis was applied to identify the independent risk factors for ST in LVT patients. A total number of 160 hospitalized LVT patients [median follow-up period 50 months (18.3-82.5 months)] were subjected to analysis. Of them, 54 (33.8%) patients developed acute myocardial infarction, 16 (10%) had ST, and 33 (20.6%) died. Comparable baseline characteristics were established between the ST and non-ST groups, except for the heart failure classification (P = .014). We obtained the following results from our multivariable analysis, based on the use of HFrEF as a reference: HFpEF [odd ratio (OR), 6.2; 95% confidence interval (CI), 1.4-26.3; P = .014] and HFmrEF (OR, 5.0; 95%CI, 1.1-22.2; P = .033). In conclusion, HFpEF, and HFmrEF may be independent risk factors for in-hospital ST development.

Massive Left Ventricular Thrombus Causing Bilateral Posterior Cerebral Artery Stroke: A Case Report and Review of Literature

Left ventricular thrombus (LVT) is a major complication of acute myocardial infarction (MI). Here, we describe the case of a 36-year-old female with a history of acute anterior MI six years prior to hospitalization, who presented with bilateral vision loss due to a bilateral embolic posterior cerebral artery (PCA) stroke in the setting of a 5.7 x 1.7 cm LVT. She underwent bilateral PCA thrombectomy, which led to improvement of her symptoms. Her LVT was managed non-surgically with apixaban and clopidogrel. Her case highlights the need for more medical education about LVT, as quick initiation of anticoagulation is essential in improving outcomes. We review the existing literature to explain the pathogenesis, diagnosis, and treatment of LVT.

Society for Cardiovascular Magnetic Resonance 2021 cases of SCMR and COVID-19 case collection series

The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). "Cases of SCMR" is a case series hosted on the SCMR website ( https://www.scmr.org ) that demonstrates the utility and importance of CMR in the clinical diagnosis and management of cardiovascular disease. The COVID-19 Case Collection highlights the impact of coronavirus disease 2019 (COVID-19) on the heart as demonstrated on CMR. Each case in series consists of the clinical presentation and the role of CMR in diagnosis and guiding clinical management. The cases are all instructive and helpful in the approach to patient management. We present a digital archive of the 2021 Cases of SCMR and the 2020 and 2021 COVID-19 Case Collection series of nine cases as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar literature search engine.

Complex adult congenital heart disease on cross-sectional imaging: an introductory overview

Congenital heart disease is the most common group of congenital pathology. Over the past few decades, advances in surgical treatment have resulted in a rising population of adult patients with repaired complex congenital heart disease. Although the quality of life has greatly improved, a significant proportion of morbidities encountered in clinical practice is now seen in adults rather than in children. These patients often have significant haemodynamic pathophysiology necessitating repeat intervention. CT and MRI are excellent imaging modalities, which help elucidate potential complications that may need urgent management. Although imaging should be performed in specialised centres, occasionally patients may present acutely to emergency departments in hospitals with little experience in managing potentially complex patients. The purpose of this article is to provide an introductory overview to the radiologist who may not be familiar with complex congenital heart disease in adult patients. This educational review has three main sections: (1) a brief overview of the post-operative anatomy and surgical management of the most common complex conditions followed by (2) a discussion on CT/MRI protocols and (3) a review of the various complications and their CT/MRI findings.

Cardiac Magnetic Resonance Tissue Characterization in Ischemic Cardiomyopathy

Ischemic cardiomyopathy (ICM) is one of the most common causes of congestive heart failure. In patients with ICM, tissue characterization with cardiac magnetic resonance imaging (CMR) allows for evaluation of myocardial abnormalities in acute and chronic settings. Myocardial edema, microvascular obstruction (MVO), intracardiac thrombus, intramyocardial hemorrhage, and late gadolinium enhancement of the myocardium are easily depicted using standard CMR sequences. In the acute setting, tissue characterization is mainly focused on assessment of ventricular thrombus and MVO, which are associated with poor prognosis. Conversely, in chronic ICM, it is important to depict late gadolinium enhancement and myocardial ischemia using stress perfusion sequences. Overall, with CMR's ability to accurately characterize myocardial tissue in acute and chronic ICM, it represents a valuable diagnostic and prognostic imaging method for treatment planning. In particular, tissue characterization abnormalities in the acute setting can provide information regarding the patients that may develop major adverse cardiac event and show the presence of ventricular thrombus; in the chronic setting, evaluation of viable myocardium can be fundamental for planning myocardial revascularization. In this review, the main findings on tissue characterization are illustrated in acute and chronic settings using qualitative and quantitative tissue characterization.

Left Ventricular Infected Thrombus Detected by 18F-FDG PET/CT and MRI in Disseminated Staphylococcus Infection

We present the case of a 61-year-old woman with fever and acute meningitis. Clinical evaluation revealed maculopapular rash, right gluteus cellulitis, and centered retinal hemorrhages. In the intensive care unit, persistent Staphylococcus bacteremia was detected. However, transesophageal echocardiography did not reveal pathologic features. F-FDG PET/CT and cardiac MRI diagnosed a left ventricular infected thrombus, an extremely rare condition especially in patients without structural cardiopathy.

Cardiovascular magnetic resonance techniques for tissue characterization after acute myocardial injury

The annual incidence of hospital admission for acute myocardial infarction lies between 90 and 312 per 100 000 inhabitants in Europe. Despite advances in patient care 1 year mortality after ST-segment elevation myocardial infarction (STEMI) remains around 10%. Cardiovascular magnetic resonance imaging (CMR) has emerged as a robust imaging modality for assessing patients after acute myocardial injury. In addition to accurate assessment of left ventricular ejection fraction and volumes, CMR offers the unique ability of visualization of myocardial injury through a variety of imaging techniques such as late gadolinium enhancement and T2-weighted imaging. Furthermore, new parametric mapping techniques allow accurate quantification of myocardial injury and are currently being exploited in large trials aiming to augment risk management and treatment of STEMI patients. Of interest, CMR enables the detection of microvascular injury (MVI) which occurs in approximately 40% of STEMI patients and is a major independent predictor of mortality and heart failure. In this article, we review traditional and novel CMR techniques used for myocardial tissue characterization after acute myocardial injury, including the detection and quantification of MVI. Moreover, we discuss clinical scenarios of acute myocardial injury in which the tissue characterization techniques can be applied and we provide proposed imaging protocols tailored to each scenario.

Late Gadolinium Enhancement Cardiac Magnetic Resonance Tissue Characterization for Cancer-Associated Cardiac Masses: Metabolic and Prognostic Manifestations in Relation to Whole-Body Positron Emission Tomography

Background

Cardiac magnetic resonance (CMR) differentiates neoplasm from thrombus via contrast enhancement; positron emission tomography (PET) assesses metabolism. The relationship between CMR contrast enhancement and metabolism on PET is unknown.

Methods and Results

The population included 121 cancer patients undergoing CMR and ¹⁸F‐fluorodeoxyglucose (¹⁸F‐FDG)–PET, including 66 with cardiac masses and cancer‐matched controls. Cardiac mass etiology (neoplasm, thrombus) on CMR was defined by late gadolinium enhancement; PET was read blinded to CMR for diagnostic performance, then colocalized to measure FDG avidity. Of CMR‐evidenced thrombi (all nonenhancing), none were detected by PET. For neoplasm, PET yielded reasonable sensitivity (70–83%) and specificity (75–88%). Lesions undetected by PET were more likely to be highly mobile (P=0.001) despite similar size (P=0.33). Among nonmobile neoplasms, PET sensitivity varied in relation to extent of CMR‐evidenced avascularity; detection of diffusely enhancing or mixed lesions was higher versus predominantly avascular neoplasms (87% versus 63%). Colocalized analyses demonstrated 2‐ to 4‐fold higher FDG uptake in neoplasm versus thrombus (P<0.001); FDG uptake decreased stepwise when neoplasms were partitioned based on extent of avascularity on late gadolinium enhancement CMR (P≤0.001). Among patients with neoplasm, signal‐to‐noise ratio on late gadolinium enhancement CMR moderately correlated with standardized uptake values on PET (r=0.42–0.49, P<0.05). Mortality was higher among patients with CMR‐evidenced neoplasm versus controls (hazard ratio: 1.99 [95% CI, 1.1–3.6]; P=0.03) despite nonsignificant differences when partitioned via FDG avidity (hazard ratio: 1.56 [95% CI, 0.85–2.74]; P=0.16). Among FDG‐positive neoplasms detected concordantly with CMR, mortality risk versus cancer‐matched controls was equivalently increased (hazard ratio: 2.12 [95% CI, 1.01–4.44]; P=0.047).

Conclusions

CMR contrast enhancement provides a criterion for neoplasm that parallels FDG‐evidenced metabolic activity and stratifies prognosis. Extent of tissue avascularity on late gadolinium enhancement CMR affects cardiac mass identification by FDG‐PET.

Distinguishing aortic valve thrombus from Libman-Sacks endocarditis in antiphospholipid syndrome: imaging and management

Aortic valve (AV) thrombus, a rare complication of antiphospholipid syndrome (APLS), is important to distinguish from Libman-Sacks endocarditis because of its responsiveness to anticoagulation. This may be attributed to immunopathologic differences underpinning their development. We present the case of a 45-year-old woman with high-risk primary APLS who developed an AV mass and was taken for valvular repair surgery but found to have pure thrombus and normal valve leaflets. In such cases, a trial of conservative management with anticoagulation may be adequate. Echocardiography, computed tomography and MRI findings suggestive of thrombus without endocarditis are presented. A literature review of histopathologic, imaging and treatment implications of pure AV thrombus in the context of APLS is included.

New perspectives by imaging modalities for an old illness: Rheumatic mitral stenosis

Mitral stenosis (MS) is a progressive and devastating disease and most often occurs among young women. Given its considerable prevalence in Mediterranean and Eastern European countries according to the Euro Heart Survey, new imaging modalities are warranted to improve the management of patients with this condition. A wide spectrum of abnormalities occurs involving all parts of this complex structure and causing different grades of MS and/or regurgitation as a consequence of rheumatic affection. Novel imaging modalities significantly improved the assessment of several aspects of this rheumatic destructive process including the morphological alterations of the mitral valve (MV) apparatus, left atrial (LA) function, LA appendage, right and left ventricular (LV) functions, and complications, namely, atrial fibrillation and thromboembolic events. Furthermore, new imaging modalities improved the prediction of outcome of patients who underwent percutaneous balloon mitral comissurotomy and changed the paradigm of patient selection for intervention and risk stratification. The present review aimed to summarize the role of new multimodality, multiparametric imaging approaches to assess the morphological characteristics of the rheumatic MS and its associated complications, and to guide patient management.

Diagnostic utility and clinical implication of late gadolinium enhancement cardiac magnetic resonance for detection of catheter associated right atrial thrombus

PURPOSE

To use delayed enhancement cardiac magnetic resonance (DE-CMR) as a reference standard to evaluate the prevalence and predictors of right atrial (RA) thrombus.

METHODS

In this retrospective study, 130 cancer patients with central venous catheters undergoing CMR from August 2012-January 2018 were included. CMR (cine-CMR and DE-CMR) and echocardiography were interpreted for RA thrombus blinded to other imaging results and clinical data. RA thrombus properties including the number of discrete masses, size, total thrombus area, and perimeter were also assessed. Cine-CMR was also used to quantify cardiac structure and function as markers of RA thrombus. Student's t-test was used to assess continuous variables; chi-square or Fisher's exact test were used to assess categorical variables.

RESULTS

31/130 (24%) patients had RA thrombus on DE-CMR. Echocardiography (attained in 64% of the study population) demonstrated moderate sensitivity and specificity (75%, 90% respectively) in relation to DE-CMR; cine-CMR performance was higher (sensitivity 90%, specificity 98%). Patients with and without RA thrombus had similar right-sided structure/function and cancer diagnosis. Catheter depth approached significance in patients with RA thrombus (p = 0.05). 13% of patients with RA thrombus had concomitant pulmonary embolism within 60 days of CMR vs. 2% of patients without RA thrombus (p = 0.03). Embolic events were independent of RA thrombus size (p = 0.66).

CONCLUSION

Morphologic imaging by cine-CMR and echocardiography provide limited diagnostic utility for RA thrombus as established by DE-CMR tissue characterization. Catheter-associated RA thrombus occurs independently of right-sided structure or function and is associated with clinical embolic events and catheter depth.

The Role of Contrast-Enhanced Cardiac Magnetic Resonance in the Assessment of Patients with Malignant Ventricular Arrhythmias

Cardiac magnetic resonance (CMR) imaging has gained significant traction as an imaging modality of choice in the evaluation of individuals with, or at risk for, heart failure. Ventricular arrhythmias, often malignant, may be sequelae of heart failure and arise from fibrosis. Late gadolinium enhancement evaluation by CMR has become a preferred modality to assess individuals at risk for malignant ventricular arrhythmias. A spectrum of various pathologies that predispose individuals to malignant ventricular arrhythmias, as well as the usefulness of CMR in their identification and prognostication, are reviewed.

Post-ischaemic exuberant left ventricular mass: thrombus vs. tumour-case report

Background

We present a case that illustrates the diagnostic challenge of differentiating thrombus from tumour when confronted with a large left ventricular (LV) cardiac mass.

Case Summary

A 43-year-old Caucasian woman polysubstance-abuser presented to a regional hospital with an ST-elevation myocardial infarction and underwent aspiration-thrombectomy and successful circumflex artery bare metal stenting. She was noted to have an exuberant LV mass on transthoracic echocardiogram the following day and transferred to our care. Transthoracic echocardiogram, transoesophageal echocardiogram, and cardiac magnetic resonance imaging were performed in an attempt to characterize the mass with conflicting findings for either thrombus or tumour. The mass was surgically excised and final pathology indicated a fibrin-rich thrombus.

Discussion

The association of the mass with an infarcted area of the left ventricle supported the diagnosis of thrombus. However, due to the size and some imaging features a myxoma could not be completely ruled out. Atypical presentations of thrombus can be difficult to differentiate from cardiac tumours.

Prominent right ventricular mass in a young patient with a history of classic testicular seminoma: a case report

BACKGROUND

The incidence of intracardiac masses is generally low. In most cases, the formation of a thrombus represents the principal diagnosis in clinical practice. The differential diagnosis mainly includes primary tumours of the heart as well as intracardiac metastases. Testicular cancer is a rare malignancy, accounting for approximately 1% of all male tumours. Cardiac metastasis of a seminoma is extremely rare.

CASE SUMMARY

A 30-year-old man with a history of a classic seminoma of the right testis was referred to our university hospital from an outside clinic. Transthoracic echocardiography showed a large space-occupying mass in the right ventricle (4.0 cm × 4.5 cm × 5.5 cm) attached to the apex and septum. Cardiac magnetic resonance imaging confirmed the finding of a 5.5 cm × 3.5 cm lesion without freely movable appendage or obstruction of the right ventricular outflow tract. Tissue characterization by T1- and T2-weighted black blood imaging revealed a signal behaviour comparable to pulmonary metastases. Additionally, positron emission tomography (PET) with 250 MBq induced 18-fluorodeoxyglucose (18F-FDG) as part of a re-staging showed significant FDG-uptake. Thus, the final diagnosis of an intracardiac metastasis of the testicular seminoma was made, and the patient was treated with cisplatin, etoposide, and bleomycin chemotherapy according to the current guidelines. A repeat trans-thoracic echocardiogram (TTE) performed 2 weeks later already demonstrated a significant reduction of the metastasis with a diameter of 3.3 cm × 3.0 cm.

DISCUSSION

In the past few years, multimodality imaging has become essential in the diagnostic evaluation of cardiac disease. In order to improve the diagnostic accuracy, a modern approach should preferably contain the integration of different imaging modalities. Cardiac magnetic resonance imaging as well as 18F-FDG-PET/computed tomography helped us reach the aetiological diagnosis of an intracardiac metastasis and to initiate prompt treatment.

Intracardiac mass in chronic myeloid leukemia

Chronic myeloid leukaemia (CML) is a neoplastic disorder of myeloid cell lines and is a less aggressive disease compared to acute myeloid leukemia (AML). Although cardiovascular complications are not uncommon, intracardiac thrombosis in CML is rarely reported. Herein, we report a case of CML presenting with an intracardiac thrombus attached to the posterior mitral leaflet, and subsequently resulting in peripheral embolization.

Effect of abnormal right heart structures on the diagnosis of pulmonary hypertension

The diagnosis of pulmonary hypertension (PH) requires a right heart catheterization (RHC) that reveals a mean pulmonary artery pressure ≥ 25 mmHg. The pulmonary artery catheter traverse the right atrium and ventricle on its way to the pulmonary artery. The presence of abnormal right heart structures, i.e. thrombus, vegetation, benign or malignant cardiac lesions, can lead to complications during this procedure. On the other hand, avoidance of RHC delays the diagnosis and treatment of PH, an approach that might be associated with worse outcomes. This paper discusses the impact of right heart lesions on the diagnosis of PH and suggests an approach on how to manage this association.

Misdiagnosis for right atrial mass: a case report

Introduction

Patients with chronic kidney disease undergoing haemodialysis (HD) therapy have high morbidity and mortality, the main causes are cardiovascular events followed by infectious disease. Infectious problems originate from the vascular access, especially when such access is through a central venous catheter.

Case presentation

We described a 72-year-old man with end-stage renal disease, requiring HD, with fever and purulent discharge at the catheter insertion site. Transthoracic echocardiography revealed a 39 × 27 mm mobile mass in the right atrium. Magnetic resonance imaging showed a 53 × 45 × 36 mm mass suggesting myxoma. The patient underwent surgery and a mass of approximately 5 × 6 cm was found attached to the floor of the right atrium, next to the inferior vena cava outlet, without affecting the tricuspid valve or the interatrial septum. Histopathology reported infected thrombus. This case confirms that sometimes it is difficult to perform a differential diagnosis between intracardiac masses. The patient showed full clinical recovery during this period and was discharged. Currently, he is in good clinical condition and attends follow-up clinic of nephrology, regularly.

Discussion

In HD patients, a high index of suspicion is very important in the early recognition and management of infective endocarditis. Imaging studies are very useful for the diagnosis of intracardiac masses, but sometimes it is difficult to differentiate one mass from another. In our case, despite the multimodal approach, the histopathological study was the one that gave us the definitive diagnosis.

Spindle-cell sarcoma involving the major pulmonary arteries

Primary pulmonary vasculature tumors are exceptionally rare, with only a few reported cases. Signs and symptoms of such neoplasms vary but include dyspnea, cough, and chest pain. This condition is associated with a high mortality rate and is easily misdiagnosed as a pulmonary artery embolism. We pre-sent a case of pulmonary artery sarcoma that demonstrates the value of cardiac magnetic resonance imaging for accurate diagnosis.