Atrial myxomas and thrombi: comparison of imaging features on CT

An Unusual Case of Cardiac Mass: A Multimodal Approach in Diagnosis and Treatment

Diagnosing intracardiac masses poses a complex, multimodal challenge. We present the case of a 72-year-old woman with a history of rheumatic fever leading to mitral stenosis and a previous mitral valve commissurotomy who reported fatigue, weakness, and palpitations over the past three months. Echocardiography revealed a tumor (53 × 40 mm) in the enlarged left atrium, attached by a wide base to the left atrium wall, exhibiting variable densities. Computerized tomography identified a heterodense mass (53 × 46 × 37 mm) with similar attachments. Angiography showed two branches from the circumflex artery intricately associated with the mass. Despite unsuccessful embolization of the mass' blood supply, surgical intervention including mitral valve replacement, tricuspid valve annuloplasty, and tumor removal was pursued. Pathohistological analysis confirmed the mass as a thrombus. During the postoperative follow-up, the patient presented with no complaints. Follow-up echocardiography indicated the normal function of the mechanical mitral valve prosthesis and the absence of intracardiac masses. While it remains unknown whether this neovascularization is specific to patients with severe mitral valve disease, this case highlights the diagnostic challenges of differentiating between thrombi and tumors in the context of mitral valve disease. It illustrates the critical role of multimodal imaging in elucidating the anatomical and functional relationships within the heart, thereby guiding accurate diagnosis and effective treatment.

Left Atrial Myxoma and Antiphospholipid Syndrome-A Case Report

Cardiac myxoma (CM) is the most frequent type of primary cardiac neoplasm and is responsible for 58 to 80% of primary cardiac tumors. The antiphospholipid syndrome (APS) occurs most commonly in the systemic lupus erythematosus but it can be also found in other conditions. The coexistence of CM and APS is rarely described in the literature. We report an unusual case of the left atrial myxoma and concomitant APS in a female patient who presented with right-sided hemiplegia. Although rare, we must think about the CM in patients with a newly diagnosed APS and left atrial mass. Nevertheless, we must make a distinction from other possible cardiac structures, especially atrial thrombus. Transthoracic echocardiography is the most frequently used initial imaging modality to detect CM. The aim of this case report was to emphasize that additional imaging modalities and multidisciplinary approach are mandatory in making a proper diagnosis and to choose a further treatment strategy.

Diagnosis of the right atrial myxoma after treatment of COVID-19: A case report

Key Clinical Message

Atrial myxoma is a rare disease but has a broad clinical presentation and complication that involves several systems- heart, lungs, brain, and systemic. An interdisciplinary approach is very important to optimize the outcome in patients with atrial myxomas. A thorough examination by primary care providers is crucial. Then radiologists or cardiologists can help with imaging modalities that can help diagnose and characterize the tumor. Prior to surgical resection by cardiothoracic surgeons, patients need to be evaluated by pulmonologists, cardiologists, and anesthesiologists for preoperative risk stratifications. In patients with neurological complications, pulmonary complications, or infectious endocarditis, input from neurologists, hematologists, infectious disease specialists is essential for patient care. In case antiplatelet/anticoagulation therapy or antibiotic treatment is warranted, pharmacists can provide valuable recommendations.

Abstract

Myxoma is the most common benign cardiac primary tumor, occurring in the right atrium in only 15%-20% of cases. This disease is asymptomatic initially depending upon size of the tumor, and symptoms develop as the tumor spreads. Atrial myxomas are associated with a triad of complications, including obstruction, emboli, and constitutional symptoms (such as fever and weight loss). This regard, embolization of the pulmonary circulation system is a complication of right myxoma. The patient was a 40-year-old male who presented to the emergency department complaining of fever and confusion. He had been previously hospitalized due to COVID-19 and treated with Remdesivir and plasmapheresis. He had tachycardia, tachypnea, thrombocytopenia, and increased liver enzymes. Chest imaging showed nodular lesions with necrotic areas and cavitary lesions in both lungs and the right atrium infected clot was seen in echocardiography. He was treated with intravenous antibiotics and finally underwent heart surgery due to the diagnosis of pulmonary septic embolism. The patient was finally diagnosed with right atrial myxoma according to heart mass histopathology. It is worth noting that the patient's thrombosis had already developed on the right atrial myxoma, which delayed the diagnosis in this patient. This thrombus formation was due to the hypercoagulability state of COVID-19 and following the insertion of a central venous catheter to perform plasmapheresis as a complication of treatment. Special attention should be paid to thromboprophylaxis and the early diagnosis of intravascular and intracardiac thrombosis in COVID-19 patients. Furthermore, the use of imaging modalities is recommended to differentiate thrombus from myxoma.

Case report: The diagnostic challenge of primary cardiac intimal sarcoma

Primary cardiac intimal sarcoma, an extremely rare cardiac tumor subtype, is often mis-diagnosed owing to its rarity and non-specific clinical and radiological features. We report a case of cardiac intimal sarcoma mimicking atrial myxoma in which the clinical presentation and multimodality imaging are described in detail, and diagnostic challenges are highlighted.

[Heart imaging by CT-scan and MRI in cardiac tumors]

The etiology of cardiac masses is often oncological or thrombotic, rarely inflammatory. Among heart tumors, the vast majority are metastatic. We describe the most frequent benign primary cardiac tumors and the most frequent malignant primary cardiac tumors and give information about the advantages of using a multi-modality approach for the accurate diagnosis of a cardiac mass using Computed Tomography Scanner and Magnetic Resonance Investigation.

Massive left atrial thrombus evades multimodality imaging as a myxoma in a bicaval heart transplant recipient

Intracardiac masses are an extremely rare and poorly described complication following a bicaval heart transplantation. We describe the case of an asymptomatic 62-year-old male with a large left atrial mass found incidentally on transthoracic echocardiography 6 years post-transplant. A battery of additional imaging tests was ordered including transesophageal echocardiography, ¹⁸ F-fluorodeoxyglucose positron emission tomography/computed tomography, and T1 and T2 magnetic resonance imaging. Although imaging biomarkers were generally nonspecific, the mass was most consistent with a cardiac myxoma. However, intraoperative findings confirmed by pathology revealed a massive organizing thrombus. The patient had an uneventful recovery after surgical removal of the mass. Our case highlights a very rare phenomenon in heart transplant recipients which remains a unique diagnostic challenge even with current advances in imaging.

Massive Mural Thrombus Masquerading as Myxoma

A 75-year-old Caucasian female with a past medical history including insulin-dependent diabetes mellitus, hypertension, and dyslipidemia, presented to the emergency room for having palpitations for three weeks. Echocardiography revealed a very large left atrial mass mimicking myxoma. Mass was excised and examined by pathology, revealing a mural thrombus. A mural thrombus is not an uncommon mass found in the left atrium. However, it does not often present symptomatically, strongly mimics an atrial myxoma on cardiac imaging, and has rarely ever been reported to be greater than seven centimeters in any dimension. We present a case of a 75-year-old Caucasian woman with a massive, symptomatic cardiac thrombus masquerading as a myxoma on imaging.

CT-based radiomics signature for differentiation between cardiac tumors and a thrombi: a retrospective, multicenter study

The study aimed to develop and validate whether the computed tomography (CT) radiomics analysis is effective in differentiating cardiac tumors and thrombi. For this retrospective study, a radiomics model was developed on the basis of a training dataset of 192 patients (61.9 ± 13.3 years, 90 men) with cardiac masses detected in cardiac CT from January 2010 to September 2019. We constructed three models for discriminating between a cardiac tumor and a thrombus: a radiomics model, a clinical model, which included clinical and conventional CT variables, and a model that combined clinical and radiomics models. In the training dataset, the radiomics model and the combined model yielded significantly higher differentiation performance between cardiac tumors and cardiac thrombi than the clinical model (AUC 0.973 vs 0.870, p < 0.001 and AUC 0.983 vs 0.870, p < 0.001, respectively). In the external validation dataset with 63 patients (59.8 ± 13.2 years, 26 men), the combined model yielded a larger AUC compared to the clinical model (AUC 0.911 vs 0.802, p = 0.037). CT radiomics analysis is effective in differentiating cardiac tumors and thrombi. In conclusion, the combination of clinical, conventional CT, and radiomics features demonstrated an additional benefit in differentiating between cardiac tumor and thrombi compared to clinical data and conventional CT features alone.

Multimodality imaging evaluation of incidentally discovered intracardiac mass

Incidentally discovered intracardiac masses often represent diagnostic dilemmas. No guideline-directed algorithm exists for evaluation and management in these cases. Understanding the utility and limitations of different imaging modalities expedites evaluation of differential diagnoses and management, particularly when there are discordant imaging findings. This case further demonstrates that benign cardiac tumors may grow rapidly, and that new and rapid emergence of an intracardiac mass does not necessarily correlate with a diagnosis of thrombus or malignancy. It also highlights the importance of a broad differential diagnosis and a systematic management approach in patients with intracardiac masses.

Cardiac myxomas: A narrative review

Cardiac myxomas are common primary neoplasms of the heart. They are biologically benign but “functionally malignant” because of the potential for embolization. They arise most commonly from the left atrium, but no chambers of the heart are immune. They may be sporadic in the majority but also familial as a part of the Carney complex. Two morphological forms exist: polypoid and papillary. Polypoid myxomas often present with obstructive features, while the papillary forms are more prone to embolization. Histogenesis is still controversial; the current view centres around origin from the primitive pluripotent mesenchymal cells. They may be of giant proportion, be calcified or get infected. Clinical presentation typically involves the triad of intracardiac obstruction, embolic events and constitutional symptoms. Precordial examination findings may simulate those of mitral or tricuspid stenosis. The presence of tumour plop and change of the physical findings with changing position may help differentiation between the two. Echocardiography is the investigation of choice. Echogenic polypoid or papillary mobile mass within the atrial cavity remaining attached to the interatrial septum through a stalk are the tell-tale echocardiographic features. Cardiac magnetic resonance and computed tomographic scanning may have incremental diagnostic value. Histopathological examination reveals abundant loose myxoid stroma with scattered round, polygonal or stellate cells with dense irregular nuclei. Genetic testing may detect mutations in the PRKAR1A gene in the familial form of cardiac myxoma, i.e. the Carney complex. Surgical excision is the mainstay of treatment with low operative mortality, excellent postoperative survival and low recurrence rate. The current trend favours minimal-access surgery with or without robotic assistance. Physicians should have appropriate preparedness to make a timely diagnosis and enthusiastic treatment to avoid potentially fatal complications.

An abscess of mitral aortic intervalvular fibrosa mimicking an intracardiac mass

BACKGROUND

Abscess of the mitral-aortic intervalvular fibrosa (MAIVF) is a rare occurrence, with its most frequently described causative associations being active or prior endocarditis, prosthetic valves, or native valves with anomalies. We report a case of infective endocarditis (IE) complicated by an abscess of the MAIVF without valvular involvement. This case highlights the importance of this rare clinical entity and of the multimodality imaging approach in reaching an accurate diagnosis and differential diagnosis.

METHODS AND RESULTS

A 35-year-old male presented with fatigue and intermittent high-grade fever for a 2-week duration. IE was suspected based on a clinical exam. Transthoracic echocardiography (TTE) demonstrated heterogeneous mass with a size of about 2.9 cm × 2.3 cm coming from the MAIVF, mimicking an intracardiac mass. Color Doppler flow Imaging showed the mass without communication with the surrounding cardiovascular cavities. Cardiac computed tomography angiography (CCTA) revealed a large low-density mass without any enhancement, which was situated adjacent to the left ventricular tract with a severely compressed left atrial chamber. The patient underwent cardiac mass removal under extracorporeal circulation. During the procedure, a large abscess was found to be located in MAIVF. The postoperative course was uneventful.

DISCUSSION

The abscess of MAIVF is a rare entity with a high risk of developing the pseudoaneurysm of MAIVF (p-MAIVF). The periaortic spread of the abscess is a dynamic process in which the inflammation of the deep tissue causes, in the first stage, a MAIVF thickening, which eventually progresses with the formation of an abscess, and subsequently, a pseudoaneurysm. Complications of p-MAIVF include rupture into the left atrium, aorta, or pericardial space leading to hemopericardium, tamponade, and death. The major differential diagnosis for abscess of MAIVF includes p-MAIVF an intracardiac mass. TTE plays a key role in the diagnosis and differential diagnosis of abscesses of MAIVF. CCTA can be a useful adjunct to further characterize abscess spread, three-dimensional spatial relationships with other cardiac structures for preoperative planning, as well as in the evaluation of potential complications such as coronary artery compromise and communication with the aorta, left atrium, or pericardial space. Surgical management is recommended in complicated, symptomatic patients to prevent further expansion of abscesses or pseudoaneurysms.

CONCLUSION

The abscess of MAIVF is a rare complication of endocarditis and surgical trauma in the MAIVF area, TTE remains a first-line imaging modality for clinically suspected periaortic abscess or other IE complications. CCTA has a complementary role to echocardiography in identification, characterization, and preoperative planning.

Radiomics Feature Analysis Using Native T1 Mapping for Discriminating Between Cardiac Tumors and Thrombi

RATIONALE AND OBJECTIVES

Accurate differential diagnosis is essential because cardiac tumors and thrombi have different prognoses and therapeutic approaches. Native T1 map provides an objective T1 time quantifications of cardiac mass without the need for a contrast agent. We examined the diagnostic performance of radiomics features for differentiating cardiac tumors from thrombi using cardiac magnetic resonance imaging T1 mapping technique compared to that of late gadolinium enhancement (LGE) imaging.

MATERIALS AND METHODS

This retrospective study included 22 cardiac tumors and 21 thrombi of 41 patients who underwent cardiac magnetic resonance imaging from December 2013 to May 2018. Fifty-six radiomics features were extracted from native T1 images. The least absolute shrinkage and selection operator method was used for feature selection and rad score extraction. The diagnostic performance of the rad score was compared to that of the native T1 value (mean T1) and LGE ratio.

RESULTS

The area under the receiver operating characteristic curve of the rad score was higher than that of the mean T1 and LGE ratio (0.98 vs. 0.86 vs. 0.82, p = 0.001). With the optimal cut-off value, the rad score showed sensitivity, specificity, and accuracy of 95.4%, 95.2%, and 95.2%, respectively. Combination of the rad score and mean T1 showed a significantly higher diagnostic performance than mean T1 (p = 0.019) or LGE ratio (p = 0.022).

CONCLUSION

The rad score derived from native T1 maps can differentiate thrombi from tumors better than the mean T1 or LGE ratio. This is valuable for determining a treatment strategy for cardiac lesions in patients who cannot tolerate contrast agents.

A Primary Neuroendocrine Tumor Mimicking a Thrombus in the Left Atrial Appendage

Most cardiac tumors are metastases, and primary cardiac tumors are rare; even among primary cardiac tumors, primary cardiac neuroendocrine tumors (NETs) are extremely rare. Herein, we report a case of a patient presenting a left atrial mass without past medical history. Because of the location and movement of the mass, as well as the patient's cerebral infarction episode, the mass was initially suspected to be a thrombus. However, the mass was surgically diagnosed as NET.

Imaging of cardiac masses: An updated overview

Studying cardiac masses is one of the most challenging tasks for cardiac imagers. The aim of this review article is to focus on the modern imaging of cardiac masses proceeding through the most frequent ones. Cardiac benign masses such as myxoma, cardiac papillary fibroelastoma, rhabdomyoma, lipoma, and hemangioma are browsed considering the usefulness of most common cardiovascular imaging tools, such as ultrasound techniques, cardiac computed tomography, cardiac magnetic resonance, and in the diagnostic process. In the same way, the most frequent malignant cardiac masses, such as angiosarcoma and metastases, are highlighted. Then, the article browses through nontumoral masses such as cysts, mitral caseous degenerative formations, thrombi, and vegetations, highlighting the differential diagnosis between them. In addition, the article helps in recognizing anatomic normal variants that should not be misdiagnosed as pathological entities.

Clinical Significance of Angiographically Detectable Neovascularity in Patients with Cardiac Myxoma

Background: Myxomas are the most common primary cardiac tumors. Angiographically detectable neovascularity (ADN) of myxoma is increasingly being reported as a result of the use of coronary angiography (CAG) to detect coronary artery disease. However, the clinical significance of these findings is not fully understood.Methods: We enrolled 59 patients with cardiac myxoma who also underwent CAG between January 2013 and October 2018. Patients were followed up for a mean of 28.9 months (range 1‐69 months). The clinical features, echocardiography measurements, pathological examination findings, CAG results, and outcomes during follow-up were compared between patients with ADN and patients without ADN.Results: ADN was found in 25 patients (42.4%). The arteries feeding the ADN included the right coronary artery (n=15), the left circumflex coronary artery (n=7), and both arteries (n=3). The patients with ADN had a higher proportion of eosinophils (3.2% vs. 2.2%, P=0.03) and higher low-density lipoprotein cholesterol level (2.7 mmol/L vs. 2.2 mmol/L, P=0.02). Myxoma pedicles were more likely to be located in the interatrial septum in patients with ADN (96% vs. 73.5%, P=0.02). No significant correlation was observed between the groups in clinical manifestations, atrial arrhythmia, myxoma size, cardiac chamber size, left ventricular ejection fraction, and the prevalence of complication with coronary artery disease [16% in the ADN group (n=4) vs. 20.6% in the non-ADN group (n=7), P=0.66]. However, patients with ADN tended to have a lower incidence of major adverse cardiac and cerebrovascular events on long-term follow-up (0% vs. 14.7%, P=0.07).Conclusion: CAG-detected ADN in patients with cardiac myxoma is associated with a borderline lower rate of major adverse cardiac and cerebrovascular events.

Left Atrial Thrombus Mimicking Myxoma Secondary to Rebound Hypercoagulable State

Novel oral anticoagulants (NOACs) have made the use of anticoagulation in patients with atrial fibrillation (AFib) much more convenient and predictable. It is a very common practice to hold anticoagulation either in anticipation of surgical procedures (to prevent excessive bleeding) or in case of acute bleeding episodes. This abrupt withdrawal of anticoagulation tilts the balance in favor of pro-thrombotic state in the body. We present a case of a 60-year-old man with past medical history of AFib who abruptly discontinued his apixaban (Eliquis). This patient presented to emergency room with the complaint of weakness and numbness of left arm and left half of the face. Stroke code was activated, and patient received tissue plasminogen activator (t-PA). This resulted in significant improvement of symptoms within hours of receiving treatment. Later during the same day, patient developed numbness and tingling of fingers of left hand. On physical exam, left hand was cold to touch and radial pulse was absent. Arterial duplex revealed occluded ulnar and radial arteries. Vascular surgery performed embolectomy to establish blood flow in the radial and ulnar arteries. Transthoracic echocardiogram revealed large left atrial mass attached to the atrial septum. Most likely t-PA infusion in the setting of atrial mass led to distal showering of emboli resulting in stenosis of radial and ulnar arteries. The left atrial mass was most likely thrombus as patient had cardiac imaging including transthoracic echocardiogram and computed tomography of heart prior to these events which did not reveal any mass in left atrium. In short, as clinicians we should be aware of the hypercoagulability associated with withdrawal of anticoagulation. In addition, we should be wary of the challenges associated with differentiating cardiac masses of different etiology.

The riddle of the right ventricle

Right ventricular (RV) myxoma is a very rare finding. Its differential diagnosis includes cardiac thrombus, and its risk of life-threatening complications mandates early diagnosis followed by surgical resection. We report the case of a patient with an incidental RV mass and a difficult differential diagnosis. A 66-year-old woman, first assessed in neurosurgery due to a lumbar herniated disc, was referred to cardiology for examination before proceeding to surgery. She complained of dyspnea on exertion present for the last few months and reported no fainting or syncope. Clinical examination showed intermittent pulmonary systolic murmur. Transthoracic echocardiography revealed an oval-shaped sessile mobile mass (42∕18 mm) attached to the anterior RV wall. Computed tomography confirmed the presence of a RV mass with lower attenuation than the myocardium and extension towards the pulmonary trunk, without other abdominal or pulmonary masses that would suggest a thrombus. Cardiac magnetic resonance imaging described an ovoid mass (47∕16 mm) in the right ventricle, "clinging" to the apical trabeculae, swinging during the cardiac cycle, causing partial obstruction of the pulmonary valve during systole. The patient underwent surgical resection of the tumor. Macroscopic specimen showed a translucent polypoid mass with hemorrhagic areas. Microscopy confirmed the diagnosis of RV myxoma. The case illustrates the difficulty of establishing the correct etiological diagnosis of a cardiac mass, especially when located in the right ventricle. Multimodality imaging remains the cornerstone of noninvasive tissue characterization of cardiac masses, still requiring histopathological confirmation, particularly in the setting of conflicting imaging results.

Distinguishing cardiac myxomas from cardiac thrombi by a radiomics signature based on cardiovascular contrast-enhanced computed tomography images

Background

Cardiac myxomas (CMs) and thrombi are associated with high morbidity and mortality. These two conditions need totally different treatments. However, they are difficult to distinguish using naked eye. In clinical, misdiagnoses occur now and then. This study aimed to compare the characteristics of CMs and cardiac thrombi and investigate the value of a radiomics signature in distinguishing CMs from cardiac thrombi, based on cardiovascular contrast-enhanced computed tomography (CECT) images.

Methods

A total of 109 patients who had CMs (n = 59) and cardiac thrombi (n = 50) were enrolled in this retrospective study from 2009 to 2019. First, the lesion characteristics of cardiovascular CECT images were documented and compared by two radiologists. Then all patients were randomly allotted to either a primary group or a validation group according to a 7:3 ratio. Univariate analysis and the least absolute shrinkage and selection operator were used to select robust features. The best radiomics signature was constructed and validated using multivariate logistic regression. An independent clinical model was created for comparison.

Results

The best radiomics signature was developed using eight selected radiomics. The classification accuracies of the radiomics signature were 90.8% and 90.9%, and the area under the receiver operating characteristic curves were 0.969 and 0.926 in the training and testing cohorts, respectively. Cardiovascular CECT images showed that the two diseases had significant differences in location, surface, Hydrothorax, pericardial effusion and heart enlargement. The naked eye findings were used to create the clinical model. All metrics of the radiomics signature were higher than those of clinical model.

Conclusions

Compared with clinical model, the radiomics signature based on cardiovascular CECT performed better in differentiating CMs and thrombi, suggesting that it could help improving the diagnostic efficiency.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01961-3.

Prevalence of intracardiac thrombi on cardiac computed tomography angiography: Outcome and impact on consequent management

Objective

Intracardiac thrombi are intermittently come across on cardiac computed tomography angiography (CCTA). This study aimed to examine the prevalence, outcome, and prognosis in patients with incidental found left-sided cardiac thrombi on CCTA.

Material and Methods

The Ethics Committee approved the present study of the Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. A retrospective review of CCTA was performed for incidental left-sided cardiac thrombi.

Results

A total of 1080 CCTAs were enrolled with the prevalence of incidental left-sided cardiac thrombi is 4.53%. Of the 49 patients with CCTA incidental left-sided cardiac thrombi, 16 had left atrial thrombi, and 33 had left ventricular thrombi. All thrombi were undetermined before the CCTA, and their identification subsequently generated anticoagulation treatment. In 10 patients, embolic complications happened, 4 of which were fatal. Patients with incidental detected left-sided intracardiac thrombi seen by CCTA had more embolic event than patients who did not discover left-sided intracardiac thrombi by CCTA (HR = 8.07; 95% CI 1.48-44.06; p = 0.016).

Conclusions

Incidental left-sided cardiac thrombi on CCTA guided to management adjustments and seemed to present substantial mortality and morbidity in the present study. Physicians who interpret CCTA should ensure a dedicated effort not to disregard these prospective pitfalls.

Management of left ventricular thrombus: a narrative review

Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. We performed a narrative literature review, manual-search of reference lists of included articles and relevant reviews. Our literature review indicates that the incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Predictors of LVT include anterior MI, involvement of left ventricular (LV) apex (regardless of the coronary territory affected), LV akinesis or dyskinesis, reduced LV ejection fraction (LVEF), severe diastolic dysfunction and large infarct size. LVT is associated with increased risk of systemic embolism, stroke, cardiovascular events and death, and there is evidence that anticoagulant therapy for at least 3 months can reduce the risk of these events. Cardiac magnetic resonance (CMR) has the highest diagnostic accuracy for LVT, followed by echocardiography with the use of echocardiographic contrast agents (ECAs). Although current guidelines suggest use of vitamin K antagonist (VKA) for a minimum of 3 to 6 months, there is growing evidence of the benefits of direct acting oral anticoagulants in treatment of LVT. Embolic events appear to occur even after resolution of LVT suggesting that anticoagulant therapy needs to be considered for a longer period in some cases. Recommendations for the use of triple therapy in the presence of the LVT are mostly based on extrapolation from outcome data in patients with atrial fibrillation (AF) and MI. We conclude that the presence of LVT is more likely in patients with anterior ST-segment elevation MI (STEMI) (involving the apex) and reduced ejection fraction (EF). LVT should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. Ongoing clinical trials are expected to elucidate the best management strategies for patients with LVT.

Severe functional mitral stenosis due to a left atrial myxoma masquerading as asthma

While cardiac myxomas are the most common primary cardiac tumours, their overall incidence remains rare. Most cases (90%) are sporadic and occur in the third–sixth decades of life with a female predominance and have a specific predilection for the left atrium (75%). While often asymptomatic, clinical presentations depend on the tumour size, architecture and location. Echocardiography remains the mainstay for diagnostic evaluation. Tumour resection is the only definitive treatment. Histopathology using H&E and immunohistochemical stains, such as calretinin and CD34, confirms the diagnosis. We present a case of a patient with reported history of asthma who presented with recurrent acute on chronic shortness of breath refractory to inhaler therapy, multiple outpatient visits and hospitalisations for ‘asthma exacerbations’. After further evaluation, she was diagnosed with a left atrial myxoma attached to the inferior aspect of the intra-atrial septum complicated by severe functional mitral stenosis.

Cardiac Tumors: JACC CardioOncology State-of-the-Art Review

Cardiac masses are rare, but remain an important component of cardio-oncology practice. These include benign tumors, malignant tumors (primary and secondary) and tumor-like conditions (e.g., thrombus, Lambl’s excrescences, and pericardial cyst). The advent of multimodality imaging has enabled identification of the etiology of cardiac masses in many cases, especially in conjunction with information from clinical settings. This paper provides a comprehensive review of the epidemiology, clinical presentation, imaging, diagnosis, management, and outcomes of cardiac masses.

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Cardiac tumors are rare and should be considered as part of the differential diagnosis of any space-occupying mass noted on cardiovascular and/or thoracic imaging modalities.

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It may be possible to get close to a diagnosis without biopsy using a structured imaging approach.

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The prognosis and treatment of each tumor is different, although early diagnosis is usually associated with a better outcome.

Case report: left atrial Myxoma causing elevated C-reactive protein, fatigue and fever, with literature review

Background

A cardiac myxoma in a young person may pose a diagnostic challenge as symptoms may be variable and the differential diagnosis is wide. The differential diagnosis can include rheumatic mitral valve disease, pulmonary hypertension, endocarditis, myocarditis and vasculitis.

Case presentation

This case report involves a 49 years old female with a 2.8 cm × 3.4 cm myxoma in the left atrium causing mitral valve obstruction. She presented with fatigue, fever of unknown origin, transient ischemic attack and shortness of breath. Prompt surgery is often recommended due to the risk of embolic complications or complete obstruction. Due to her symptoms, patient underwent successful cardiothoracic surgery to excise the myxoma within 2 weeks of confirmation by cardiac echocardiography.

Conclusion

This case also emphasizes the diagnostic challenge as symptoms may be variable, ranging from fatigue, fever and shortness of breath to transient ischemic attack and at worst, sudden cardiac death. In conclusion, if a cardiac mass is suspected, echocardiography should be performed early. Surgical resection is curative and recurrence rate is very rare in sporadic isolated myxomas, however, recurrence can be higher in genetic diseases associated with increased frequency of myxomas such as Carney complex. This subpopulation of patients may present further research opportunity to learn more about the perioperative management of patients with myxomas such as determining the optimal time to surgical intervention and decision to anticoagulate.

Assessment of Cardiac Masses by Cardiac Magnetic Resonance Imaging: Histological Correlation and Clinical Outcomes

Background

Cardiac magnetic resonance imaging (CMR) provides useful information for characterizing cardiac masses, but there are limited data on whether CMR can accurately distinguish benign from malignant lesions. We aimed to describe the distribution and imaging characteristics of cardiac masses identified by CMR and to determine the diagnostic accuracy of CMR for distinguishing benign from malignant tumors.

Methods and Results

We examined consecutive patients referred for CMR between May 2008 and August 2013 to identify those with a cardiac mass. In patients for whom there was histological correlation, 2 investigators blinded to all data analyzed the CMR images to categorize the mass as benign or malignant. For benign masses, readers were also asked to specify the most likely diagnosis. Benign masses were defined as benign neoplastic or non‐neoplastic. Malignant masses were defined as primary cardiac or metastatic. Of 8069 patients (mean age: 58±16 years; 55% female) undergoing CMR, 145 (1.8%) had a cardiac mass. In most cases (142, 98%), there was a known cardiac mass before the CMR study. Among 145 patients with a cardiac mass, 93 (64%) had a known history of malignancy. Among 53 cases that had histological correlation, 25 (47%) were benign, 26 (49%) were metastatic, and 2 (4%) were malignant primary cardiac masses. Blinded readers correctly diagnosed 89% to 94% of the cases as benign versus malignant, with a 95% agreement rate (κ=0.83).

Conclusions

Although CMR can be highly effective in distinguishing benign from malignant lesions, pathology remains the gold standard in accurately determining the type of mass.

Pulmonary embolism as the initial manifestation of right atrial myxoma: A case report and review of the literature

RATIONALE

Pulmonary embolisms (PEs) are caused by emboli, which mostly originate from deep venous thrombi that travel to and suddenly block the pulmonary arteries. The emboli are usually thrombi, and right atrial myxoma emboli are rare.

PATIENT CONCERNS

A 55-year-old man presented with shortness of breath and syncope. We proceeded with computed tomography pulmonary angiography (CTPA) and transthoracic echocardiogram (TTE), the results of which suggested that the diagnosis was a right atrial mass.

DIAGNOSIS

A definitive diagnosis compatible with a right atrial myxoma (RAM) with tumoral pulmonary emboli after surgical excision was made.

INTERVENTION

Right atrial and pulmonary artery embolectomy.

OUTCOMES

The patient followed an uneventful course during the 6 years of follow-up after surgery. According to a review of the literature, RAMs are often not diagnosed in a timely manner or even go completely undiagnosed. TTE, transesophageal echocardiography (TEE), CT, magnetic resonance imaging (MRI), and positron emission tomography/computed tomography may be helpful in the preoperative diagnosis. Surgical removal of the masses from the atrium and pulmonary arteries was relatively uneventful.

LESSONS

RAMs should be considered unlikely reasons for fatal pulmonary embolisms.

A case report of atrial myxoma presenting with systemic embolization and myocardial infarction

Background

Cardiac myxomas are the most common benign primary tumour of the heart. Clinical presentation is variable and ranges from constitutional symptoms to clinical features due to intracardiac obstruction, such as mitral stenosis, coronary embolization, or systemic embolization. Surgical resection is the only effective treatment to prevent its debilitating and catastrophic complication.

Case summary

A 61-year-old woman presented with an-hour history of bilateral leg pain, numbness, lightheadedness, dyspnoea, and diaphoresis. Physical exam was remarkable for pale and cold lower extremities. Arterial pulse was not palpable in the right femoral, popliteal, and posterior tibial and dorsalis pedis arteries bilaterally. Electrocardiogram demonstrated normal sinus rhythm with T-wave inversion in lead I, V2, V3, and V4. Laboratory investigations were remarkable for leucocytosis and elevated troponin. Computed tomography angiogram showed emboli with acute infarcts involving the spleen and kidneys, acute embolic occlusion of right external and internal iliac arteries, and left distal common femoral artery. She underwent emergent bilateral cut-down and femoral artery thrombectomies. Transthoracic echocardiogram demonstrated wall motion abnormalities. Computed tomography angiography of the chest revealed an atrial mass and transoesophageal echocardiography was obtained which confirmed an atrial myxoma. Coronary angiography demonstrated no significant coronary artery disease, raising the possibility of myxoma embolization to the coronary arteries as the cause of her troponin elevation and wall motion abnormality. Subsequently she underwent successful resection of the atrial myxoma.

Discussion

The majority of cardiac myxomas are sporadic and arise from the left atrium as an isolated lesion in middle-aged women. Echocardiography is the diagnostic procedure of choice. The long-term survival after surgical resection is excellent and recurrence is rare.

A case series of right atrial mass in neonates: a diagnostic dilemma

The diagnosis of a right atrial mass in a neonate should be treated as an emergency. There are three major differential diagnoses for a right atrial mass-thrombus, infectious vegetation, and myxoma. Embolization of the mass can result in life-threatening complications and hence timely diagnosis and treatment is vital. This case series describes the clinical course, management, and outcome of four neonates who presented with a right atrial mass.

Significant incidental cardiac disease on thoracic CT: what the general radiologist needs to know

Objective

Incidental cardiac findings are often found on chest CT studies, some of which may be clinically significant. The objective of this pictorial review is to illustrate and describe the appearances and management of the most frequently encountered significant cardiac findings on non-electrocardiographically gated thoracic CT. Most radiologists will interpret multidetector chest CT and should be aware of the imaging appearances, significance, and the appropriate next management steps, when incidental significant cardiac disease is encountered on thoracic CT.

Conclusion

This article reviews significant incidental cardiac findings which may be encountered on chest CT studies. After completing this review, the reader should not only be familiar with recognizing clinically significant cardiac findings seen on thoracic CT examinations but also have the confidence to direct their further management.

Homocystinuria presenting as a calcified right atrial mass

Homocystinuria is a genetic inborn error of metabolism due to the deficiency of cystathionine β-synthase resulting in increased serum homocysteine and methionine and decreased cysteine which predisposes affected individuals to arterial and venous thromboembolic phenomena. We present a case of homocystinuria who presented to us as a calcified right atrial mass during the evaluation for lower respiratory tract infection. Our case reveals an unusual mix of findings using imaging with multiple detector computed tomography and radiographs.

Left atrial appendage myxofibrosarcoma: A rare masquerader of myxoma and thrombus-"all that glitters is not gold"

Left atrial appendage mass can occasionally pose a serious challenge to physicians to identify the nature of the mass with the aid of imaging techniques. We present a case of 67-year-old man, who was evaluated for suspected left atria myxoma. Transesophageal echocardiography revealed a heterogeneous density originating from left atrial appendage, thought to be most consistent with a myxoma. Cardiac magnetic resonance imaging, uncharacteristically, gave an equivocal picture, suggesting the mass to be a myxoma on initial imaging and a thrombus with evidence of liquefaction necrosis following postcontrast enhancement. Surprisingly, histopathology of the mass following its surgical excision yielded a rare diagnosis of myxofibrosarcoma.

Multi-modality imaging of a left atrial myxoma

Objectives

Although echocardiography has traditionally been used to diagnose myxoma, invasive or non-invasive coronary angiography can be useful diagnostic tool before surgery.

Methods

We present a case of an angiographically detected left atrial myxoma feeding from the left circumflex coronary artery.

Results

The patient underwent open-heart surgery to remove the left atrial myxoma. After ligation of feeding artery, the mass was successfully excised.

Conclusion

Preoperative coronary angiography can offer additional valuable information moreover detecting coronary artery disease. Because, there is sudden death risk from embolization during invasive coronary angiography, preoperative cardiac computed tomography angiography should be considered to plan the surgery of myxoma.

Intense 18F-FDG uptake in an organizing right atrial thrombus mimicking malignancy

We present a case of an intensely hypermetabolic intracavitary cardiac mass, standardized uptake values max 44.4, that was pathologically proved to be organizing and organized thrombus, negative for tumor. Our patient had previous right atrial mass resection 2 years prior that was pathologically described as either thrombus or infarcted atrial myxoma. She had since been on lifelong controlled anticoagulation; and on routine follow-up imaging, she had recurrent slow growth of a new right atrial mass. During a later hospital admission for chest pain, the mass was evaluated on both transthoracic and transesophageal echo cardiogram, which could not differentiate thrombus vs neoplasm. Cardiac magnetic resonance imaging was equivocal for mass enhancement. The patient underwent fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) evaluation, which revealed intensely hypermetabolic activity within the mass concerning for malignancy, potentially an aggressive tumor. Subsequently, the mass was surgically excised for pathological diagnosis.

Preoperative assessment of mitral valve abnormalities in left atrial myxoma patients using cardiac CT

Background

To retrospectively evaluate mitral valve abnormality in left atrial myxoma patients by using cardiac computed tomography (CT).

Material and methods

Cardiac CT was performed in 56 patients with left atrial myxoma and 50 controls. Tumor and mitral valve characteristics were analyzed. The mitral valve parameters differences were compared between patients with myxoma and controls, myxoma with or without mitral valve obstruction, different obstruction degrees, respectively. Receiver operating characteristic analysis was performed to determine the cut-off values of abnormal mitral valve parameters for myxoma patients. Multiple linear regression, logistic regression models and cox regression analysis were used to determine factors associated with mitral valve abnormalities, mitral obstruction, mitral regurgitation and postoperative recovery, respectively.

Results

Myxoma induced the dilation of mitral valve, with different results among different degrees of obstruction (p<0.001). Mitral valve parameters had relationship with myxoma parameters. The cut-off values for discriminating mitral valve abnormalities in myxoma patients were found. Some significant predictors for mitral obstruction were tumor pedicle-tumor volume and patient age (HR, 0.886-30.811; p = 0.011-0.043). Moreover, the predictor for mitral regurgitation was mitral annulus diameter in diastolic phase (HR, 20.862; 95%CI,1.331-327.100; p = 0.031). Some predictors associated with postoperative recovery of mitral regurgitation were age, mitral annulus area, mitral annulus diameter and mitral valve diameter cutoff value for diastolic phase (HR, 0.001-119.160; p = 0.012-0.028).

Conclusion

Cardiac CT is capable of quantitatively assessing myxoma characteristic and mitral valve abnormality induced by myxoma, thus providing guidance of operative management and postoperative evaluation.

Radiological characteristics of atrial myxoma in Cardiac Computed Tomography

BACKGROUND

Although the primary role of Cardiac Computed Tomography (CCT) is assessment of the coronary arteries, the technique also allows detailed examination of cardiac structures and other cardiac pathologies including cardiac myxoma. However, limited data exists regarding the CCT characteristics of cardiac myxoma.

OBJECTIVE

To describe the radiological characteristics of a series of cardiac myxomas in CCT.

METHODS

We retrospectively identified all patients at our tertiary urban referral centre with cardiac myxoma on CCT over a seven-year period between July 2008 and July 2015. We describe the CCT characteristics of eight cases. Seven of them had histologically documented myxoma after surgical removal, while one patient had a lesion suggestive of myxoma on echocardiography and CCT.

RESULTS

Eight patients were diagnosed with cardiac myxoma, comprising five females and three males. Seven of eight myxomas were located in the left atrium and one in the right atrium. Seven myxomas were polypoid in shape and one myxoma was villous. The average size was 22 × 26 mm. Calcification was present in half of the myxomas and average attenuation was 74 ± 46 Hounsfield Units.

CONCLUSION

CCT has an important role in assessment of cardiac structures. This series highlights the radiological characteristics of cardiac myxoma.

Left atrial myxoma in a patient with a biventricular pacemaker

Myxomas make up about 50% of benign cardiac neoplasms. The most common location is within the left atrium. At the initial stage they do not exhibit any specific clinical symptoms, so they are often diagnosed by accident or during examinations recommended for other reasons. Here we present a case of left atrium myxoma in a patient (a man, age 68 years) with a dual chamber pacemaker. The myxoma did not reveal any clinical symptoms and was discovered in echocardiography during routine diagnostic examination preceding pacemaker implantation. The literature search made by the authors showed that this is the first recorded case of myxoma in a patient after the implantation of a biventricular pacemaker.

Right-atrial myxoma clinically mimicking recurrence of rheumatic valve disease long time after mitral valve repair

Right atrial myxomas are rare. Its occurrence in a previously operated patient of rheumatic mitral stenosis posed clinical diagnostic challenge. We herein report a case of right atrial myxoma who had undergone mitral valve repair 20 years ago and now presented in congestive heart failure. The tumor was arising from the ostium of the coronary sinus and prolapsed into the right ventricle causing significant right ventricular inflow and outflow obstruction. Urgent repeat cardiac surgery was successfully performed to remove the tumor along with mitral valve replacement. We review the diagnostic and therapeutic problems resulting from this unusual association.

Posterior wall as atypical localization of left atrial myxoma : Diagnosis and management

Atrial myxomas are the most common benign cardiac neoplasms. Although the majority occur in the left atrium (LA) and are attached to the interatrial septum (75-80 % of cases), they can arise from any part of the LA and the cardiac chambers. We report the case of a 65-year-old woman who presented with features of worsening dyspnea and persistent headache. During transthoracic echocardiography, a suspected cardiac myxoma was found arising from the posterior wall of the LA.

Point-of-Care Ultrasound Diagnosis of a Catheter-Associated Atrial Thrombus

BACKGROUND

Emergency physicians can utilize point-of-care thoracic ultrasound to aid in the diagnosis of a variety of cardiovascular and respiratory complaints.

CASE REPORT

An emergency physician utilized point-of-care cardiac ultrasound to identify catheter-associated atrial thrombi in a hemodialysis patient presenting with dyspnea. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Based on this case, point-of-care ultrasound can be utilized in patients with central venous catheters, to identify intracardiac thrombi as the cause of dyspnea, thereby facilitating appropriate consultation and treatment.

A rare appearance of a large mural thrombus in left atrium detected two years after the Maze procedure

A 77-year-old Japanese woman underwent bioprosthetic aortic valve replacement (AVR) and the Maze procedure for severe aortic valve disease and paroxysmal atrial fibrillation (AF), and one year after the AVR, she also underwent a permanent pacemaker implantation for sick sinus syndrome. At two postoperative years, a large mural mass happened to be detected in her left atrium on routine trans-thoracic echocardiography. The cardiac rhythm records produced by the implanted pacemaker demonstrated the recurrence of AF. As anticoagulant therapy was not effective at reducing the size of the mass, surgery was performed and organized thrombus was detected on the ablation line made at the Maze procedure. <Learning objective: The formation of large mural thrombi in the left atrium after the Maze procedure is rare in patients without mitral valve disease. The thrombus was considered to have been caused by several complex factors, including atrial wall damage brought by the Maze procedure and the recurrence of atrial fibrillation (AF). It is important to be aware that the recurrence of AF after the Maze procedure can carry a risk of unexpected mural thrombus formation in the left atrium.>.

Right Atrial Calcified Ball Thrombus Mimicking a Myxoma

An 80-year-old woman was admitted to our hospital because of congestive heart failure. Transthoracic echocardiography revealed severe aortic valve stenosis, and a mobile calcified mass was attached to the interatrial septum in the right atrium. We suspected that the mass was cardiac myxoma. We urgently performed aortic valve replacement and resection of the mass. The histological diagnosis of the mass was thrombus, and her post-operative course was uneventful. Although the mechanism of right atrial thrombus formation in our case was unclear, it is important to continue anticoagulation therapy after surgery to avoid recurrence. Furthermore, strict follow-up in this patient is needed.

MDCT of interatrial septum

ECG-gated cardiac multidetector row computed tomography (MDCT) allows precise analysis of the interatrial septum (IAS). This pictorial review provides a detailed description of the normal anatomy, variants and abnormalities of the IAS such as patent foramen ovale, congenital abnormalities such as atrial septal defects as well as tumors and tumoral-like processes that develop on the IAS.