Comparison of Clinical and Echocardiographic Characteristics between Cardiac Myxomas and Masses Mimicking Myxoma

Navigating complex cardiac complications: A case report of alcoholic cardiomyopathy and right atrial thrombosis

RATIONALE

Alcoholic cardiomyopathy (ACM) is associated with various cardiac complications, but the development of isolated right atrial (RA) thrombus without deep vein thrombosis is rare and presents diagnostic challenges.

PATIENT CONCERNS

A 53-year-old Hispanic male presented with shortness of breath, chills, cough, bilateral lower extremity edema, and distended abdomen.

DIAGNOSES

The patient was diagnosed with ACM, liver cirrhosis, and a large RA thrombus. Initial transthoracic echocardiography showed severe left ventricular systolic dysfunction but failed to detect the RA mass. Subsequent computed tomography scan and transesophageal echocardiography revealed a large oval mass in the RA, measuring 40 mm × 22 mm × 18 mm.

INTERVENTIONS

The patient received guideline-directed medical therapy for heart failure and anticoagulation with enoxaparin. He underwent cardiac catheterization for mechanical thrombectomy, which was minimally successful.

OUTCOMES

The patient's condition was managed with the prescribed interventions. Regular follow-up was planned to assess thrombolysis.

LESSONS

RA thrombosis is an uncommon complication of ACM. A multimodal imaging approach, with a low threshold for transesophageal echocardiography, is crucial in evaluating patients with ACM who present with cardiac complications. This approach enables accurate diagnosis and management of rare conditions like isolated RA thrombosis.

Multimodal Imaging Approach to Atrial Myxoma to Optimize Surgical Management

Cardiac masses are rare and of the neoplastic group, myxomas are the most common. An elderly male with a background of multiple myeloma and previous autologous stem cell transplant presented with dyspnea and chest heaviness with a subsequent cardiac mass found. Multimodal imaging, including three-dimensional (3D) echocardiography and cardiac magnetic resonance (CMR) imaging, was utilized to guide the diagnostic process, particularly given the differential of a cardiac plasmacytoma in the setting of multiple myeloma. CMR was used to identify characteristic features of the mass and 3D echocardiography highlighted the anatomical relationships of the mass in relation to surrounding structures to complement surgical planning. The different imaging approaches and clinical decision-making were implemented to aid in definitive surgical management.

Multimodality Imaging of Cardiac Myxomas

Cardiac myxomas are the most common benign cardiac neoplasms. Echocardiography is the first-line imaging modality used to analyze cardiac masses, allowing the detection of tumor location, size, and mobility. However, additional imaging techniques are required to confirm the diagnosis, evaluate tissue characteristics of the mass, and assess potential invasion of surrounding structures. Second-line imaging includes cardiac magnetic resonance imaging (MRI) and/or computed tomography (CT) depending on availability and the patient's characteristics and preferences. The advantages of CT include its wide availability and fast scanning, which allows good image quality even in patients who have difficulty cooperating. MRI has excellent soft-tissue resolution and is the gold standard technique for noninvasive tissue characterization. In some cases, evaluation of the tumor metabolism using 18F-fluorodeoxyglucose positron emission tomography with CT may be useful, mainly if the differential diagnosis includes primary or metastatic cardiac malignancies. A cardiac myxoma can be identified by its characteristic location within the atria, typically in the left atrium attached to the interatrial septum. The main differential diagnoses include physiological structures in the atria like crista terminalis in the right atrium and the coumadin ridge in the left atrium, intracardiac thrombi, as well as other benign and malignant cardiac tumors. In this review paper, we describe the characteristics of cardiac myxomas identified using multimodality imaging and provide tips on how to differentiate myxomas from other cardiac masses.

Series of patients operated for masses and cysts in the heart in a Spanish general hospital: A 20-year experience

BACKGROUND

Masses and cysts in the heart are well-known entities, but their low prevalence and non-specific symptoms makes the diagnosis difficult. We aimed to characterize the features of these entities in our environment.

METHODS

We carried out a search of patients who underwent surgery for tumors and cysts in the heart between 2002 and 2022 in the registry of the Department of Cardiology and Cardiac Surgery of Clínica Universidad de Navarra (Pamplona, Spain). Sociodemographic, clinical, histological, and surgical variables were collected.

RESULTS

We identified 13 patients; mean age was 63.08 ± 15.17 years, 76.92% were female and 92.31% had at least one cardiovascular risk factor, e.g., BMI = 25 kg/m2 and high blood pressure (61.54% and 53.85%, respectively). The most common type of cardiac tumors were myxomas (69.23%). Around half (46.15%) were incidental; the most frequent symptom was dyspnea (53.85%); 30.77% of the patients were asymptomatic. The most commonly used imaging technique for the diagnosis was transthoracic Doppler echocardiography (69.23%). The agreement between the mean diameters before and after surgery was very high (ICC = 0.807, 95% CI: 0.450 - 0.943).

CONCLUSIONS

We describe the features of masses and cysts in the heart (77% female patients) and provide information scarcely available in the literature, e.g., the most frequent cardiovascular risk factors for this population. A case of cardiac leiomyosarcoma and a case of intimal sarcoma of the pulmonary trunk are described, two extremely rare tumors for which there are few described cases.

Cardiac osteosarcoma: a case report and literature review

Background

Primary cardiac tumors are rare, and malignant primary cardiac tumors are even rarer. Cardiac osteosarcoma is a very rare type of malignant primary cardiac tumor with limited reported cases. We present a case report of cardiac osteosarcoma and review its characteristics and the related literature.

Case summary

A 44-year-old female patient without a specific medical history presented with intermittent dyspnea that started 1 month prior to presentation. A heterogeneous mass was observed in the left atrium on echocardiography and a large mass was observed in the left atrium on computed tomography. Surgery was performed under the suspicion of atypical cardiac myxoma, and the tumor was successfully removed. However, postoperative histopathological examination revealed cardiac osteosarcoma. The patient underwent chemotherapy and has been well maintained without recurrence for 10 years.

Conclusion

We present a case report of the echocardiographic features and treatment strategies for cardiac osteosarcoma, an extremely rare cardiac tumor. Multimodal imaging can be helpful; however, a histological diagnosis through surgical resection is essential. Appropriate treatment and follow-up based on histological findings are necessary.

Asymptomatic Pulmonic Valve Mass: A Diagnostic and Therapeutic Dilemma

Cardiac masses are not common but remain important in cardiology practice as they can cause havoc to a patient's life through obstructive and arrhythmogenic symptoms. These lesions mostly include vegetation, thrombi, and tumors. Myxomas are the most common primary cardiac tumor, primarily arising from the left heart chambers. It is exceedingly rare for a myxoma to emerge from the right-sided cardiac valves. The standard treatment is surgical resection, regardless of size, which is not always possible. We report a unique case of a male with multiple co-morbidities who presented with an incidental finding of a pulmonary valve mass suspicious of being a myxoma. The myxomatous mass was asymptomatic with no right ventricular outflow tract obstruction. Echocardiogram can help identify and characterize these lesions, but this may not be easy, especially in the case of atypical location or morphology of the mass. Similarly, in some cases, the patient may not be able to undergo surgical excision. In such cases, there is no consensus or guidelines to help clinicians best manage the patients medically, creating a diagnostic and therapeutic dilemma.

Features of the Blood Supply of Cardiac Myxoma which Can Cause Bleeding

With a mortality rate of 1 % to 5 %, surgical treatment of cardiac myxomas (CM) may be complicated by the development of intra- or postoperative bleeding, among other things. The aim. To present an unusual case of surgical treatment of left atrial myxoma with the occurrence of intraoperative bleeding, which was due to extremely rare features of the coronary circulation with a special blood supply to the base of the CM. Case report. Female patient R., 65 years old, case record No.3686, was admitted to the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine with diagnosis of CM. Coronary angiography revealed unique features of coronary circulation: an arteriovenous malformation from the distal parts of the circumflex branch of the left coronary artery with discharge into the right parts of the heart was revealed. On 9/20/2022, urgent operation of resection of the myxoma of the left atrium (LA) was performed. After removal of the myxoma and sealing of the heart, accumulation of arterial blood was found in the area of the inferior vena cava (IVC) and the interatrialsulcus. Revision of the left atrium cavity was performed again:all intracardiac sutures in the area of the myxoma base were duplicated. After repeated resealing of the heart chambers, bleeding from the IVC region stopped after administration of protamine sulfate and tight tamponade of the space under the IVC. Tampons were removed from the pericardial cavity after 72 hours. Results. The source of the bleeding could be the site of the malformation of the coronary arteries, which is a tangle of small vessels located in the projection of the base of the myxoma below the point where the IVC meets the right atrium. During the histological examination of the myxoma, large full-blood vessels of the sinusoidal type were revealed, around which, due to damage to their thin walls, hematomas formed, giving the tumor a spotted appearance. The peculiarity of this tumor was the presence of a very large vascular plexus at its base; it had the appearance of a cluster of sections of numerous, different-sized, deformed and remodeled arteries. These data were confirmed by coronary angiography. Conclusions. Studying the data of coronary angiography with the analysis offeatures of localization of coronary arteries, as well as the presence of possible coronary malformations, can provide information that allows predicting the possibility of their damage, especially in the case of localization in the place of possible surgical manipulation. In the event of bleeding, one of the optimal methods of its elimination is the use of long-term tamponade.

Cardiac myxoma: single tertiary centre experience

BACKGROUND

Although cardiac myxoma (CM) are rare and benign, they can cause life-threatening complications, such as hemodynamic disturbances or embolization. Surgical excision of the tumour is the treatment of choice. The aim of the study was to evaluate the epidemiological characteristics, clinical presentation, imaging findings, and outcomes of surgical treatment of patients with CM treated in the largest tertiary care centre in Slovenia.

PATIENTS AND METHODS

We retrospectively analysed the medical records of all patients referred to our institution between January 2005 and December 2020 and identified 39 consecutive adult patients with pathologically confirmed CM.

RESULTS

The average annual incidence of CM in the study was 3 per 2 million population per year. Patients were more often female (n = 25, 64%). The mean age at diagnosis was 63.1 ± 13.6 years. Dyspnoea was the most common presenting symptom (31%). CM was an incidental finding in 11 patients (28%). Seven patients presented with thromboembolic event (18%). Transthoracic echocardiography (TTE) was performed in all patients, however additional imaging was required in 22 patients (56%). All patients in our series were successfully treated surgically without in-hospital mortality. During the follow-up period (6 months to 16 years) three patients (8%) died, and all deaths were unrelated to CM. There was no recurrence of CM during the follow-up.

CONCLUSIONS

Our single-centre study confirms that CM is rare cardiac tumour with diverse clinical presentation. Our data shows data that CM might be more prevalent than considered before. Surgical resection of the tumour is safe with excellent short- and long-term outcomes.

Concomitant Multiple Coronary Artery Embolizations and Bilateral Lower Limb Ischemia due to Dislodged Left Atrial Myxoma-Like Thrombus

The differential diagnosis of intracardiac masses is challenging. Cardiac myxomas are benign primary heart tumors and most often are confused with thrombi in diagnosis. In some cases, the embolic complication of intracardiac masses can be fatal. We present a patient who had two nightmare complications simultaneously. A mobile left atrial mass detected and decided surgical excision. But the mass had vanished one day after and caused ST-elevation myocardial infarction (STEMI) and bilateral lower limb ischemia.

Clinical and echocardiographic characteristics of cardiac blood cysts

BACKGROUND

Cardiac blood cysts (BCs) are rare benign cardiac masses. This study aimed to summarize the clinical and echocardiographic characteristics and clinical outcomes of patients with BCs.

METHODS

This retrospective study enrolled patients diagnosed with BC between 2009 and 2021 at a single center in China. Their clinical and echocardiographic characteristics, management, and outcomes at follow-up are summarized.

RESULTS

The study population comprised 26 patients with BCs with a mean age of 40 ± 19 years (median, 42 years; range, 27-56 years). The cohort was predominantly male (16, 62%). Twenty-two (81%) patients were symptomatic: dyspnea or exertional dyspnea (11, 42%) and palpitations (6, 23%) were the most frequent symptoms. Most cysts appeared as single round, oval, or lobulated anechoic masses, measuring 4-30 mm (mean, 18 mm). Half of the BCs (13, 50%) were pedunculated and mobile, and the others swung with the movement of the valve. The mitral valve (13, 50%) was the most common site of occurrence, followed by the tricuspid valve (6, 23%), right atrium (4, 15%), and aortic valve (3, 12%). Contrast echocardiography, which was performed for two patients, revealed a closed cyst without bubbles. Five cases were complicated by left ventricular outflow tract obstruction and six by valve prolapse. Eighteen patients underwent surgery, and one received antiplatelet therapy. Cardiovascular or cerebrovascular events did not occur in any patient during the follow-up period.

CONCLUSION

Cardiac BCs are most commonly attached to the atrioventricular valve. Echocardiography is considered to be the most useful imaging modality for assessing BC. The management of patients with BC should be individualized based on the symptoms and associated complications.

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.

Cardiac myxomas: clinical presentation, diagnosis and management

Cardiac myxomas (CM) are the most common type of primary cardiac tumours in adults, which have an approximate incidence of up to 0.2% in some autopsy series. The purpose of this review is to summarise the literature on CM, including clinical presentation, differential diagnosis, work-up including imaging modalities and histopathology, management, and prognosis. CM are benign neoplasms developed from multipotent mesenchyme and usually present as an undifferentiated atrial mass. They are typically pedunculated and attached at the fossa ovalis, on the left side of the atrial septum. Potentially life-threatening, the presence of CM calls for prompt diagnosis and surgical resection. Infrequently asymptomatic, patients with CM exhibit various manifestations, ranging from influenza-like symptoms, heart failure and stroke, to sudden death. Although non-specific, a classic triad for CM involves constitutional, embolic, and obstructive or cardiac symptoms. CM may be purposefully characterised or incidentally diagnosed on an echocardiogram, CT scan or cardiac MRI, all of which can help to differentiate CM from other differentials. Echocardiogram is the first-line imaging technique; however, it is fallible, potentially resulting in uncommonly situated CM being overlooked. The diagnosis of CM can often be established based on clinical, imaging and histopathology features. Definitive diagnosis requires macroscopic and histopathological assessment, including positivity for endothelial cell markers such as CD31 and CD34. Their prognosis is excellent when treated with prompt surgical resection, with postsurgical survival rates analogous to overall survival in the age-matched general population.