Cardiac tumors

Clinical and laboratory manifestations, ECG findings, and outcomes of right atrial myxoma: a systematic review of cases reported worldwide

BACKGROUND

The presence of cardiac myxoma in the right atrium (RA) is rare. There is limited knowledge regarding the clinical symptoms and diagnosis of RA myxoma. This systematic review aimed to provide a summary of the clinical and laboratory characteristics, electrocardiogram (ECG) findings, and outcome previous cases with RA myxoma.

METHODS

A comprehensive search was conducted in PubMed, Web of Science, and Scopus to identify relevant studies. Inclusion criteria were case reports and case series written in English that provided sufficient data on the manifestation of RA myxoma. Descriptive statistics were used for quantitative analysis.

RESULTS

The search identified 619 patients from 480 eligible studies. The patient's mean age was 45.7 ± 17.6 years, and 55.4% of cases were female. The most common clinical manifestations of RA myxoma were cardiac, systemic, and neurologic manifestations which reported in 77.0%, 34.8%, and 21.1% of cases, respectively. Besides, 11.7% of RA myxoma were asymptomatic. ECG findings revealed normal in 39.4% reported cases. The ECG abnormalities included tall or peaked P-wave, RA and LA enlargement (19.2%), abnormal T-wave (14.0%), sinus tachycardia (11.8%), and incomplete or complete RBBB (11.2%). Echocardiography remained the diagnostic method in a majority of the cases. The mortality rate of RA myxoma was low (9.2%) during the follow-up.

CONCLUSIONS

This systematic review provides a comprehensive summary of the clinical and laboratory manifestations and outcomes of RA myxoma, contributing to the existing knowledge on this rare cardiac tumor.

Large Left Atrial Myxoma Discovered During Restaging of Breast Cancer

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Rare cardiac metastasis of lung cancer mimicking aneurysm and tamponade

Metastasis of non-small cell lung carcinoma (NSCLC) is a rare cause of cardiac metastatic tumors (CMT). We present a case of NSCLC infiltrating the apical left ventricle mimicking cardiac aneurysm and tamponade. The patient, who had a history of NSCLC, presented with acute shortness of breath and an echocardiogram concerning for ruptured left ventricular aneurysm. A neoplastic mass found at the cardiac apex suggested CMT leading to ventricular wall rupture and cardiac tamponade. Transthoracic echocardiography is the most ubiquitous imaging modality for CMT diagnosis, with cardiac magnetic resonance imaging offering a more detailed assessment. CMT from NSCLC can cause dangerous cardiac tamponade, warranting consideration in patients with suspected metastases.

Secondary cardiac lymphoma presenting with cardiac tamponade and cardiac mass: a case report

BACKGROUND

Cardiac tamponade as the presenting manifestation of systemic lymphoma is relatively uncommon. Pericardium is the commonest site of involvement in secondary malignancies with systemic lymphoma involving the heart in 20% of the cases.

CASE PRESENTATION

We describe a case of a 78-year-old gentleman, who presented with symptoms of new onset cardiac failure, and hemodynamic compromise. An echocardiography revealed cardiac tamponade, necessitating an emergency pericardiocentesis. With the aid of multimodality imaging, he was found to have a right atrioventricular groove mass, widespread lymph node enlargement with bone and peritoneal involvement. Ultimately, a histopathological evaluation revealed a diagnosis of Diffuse Large B Cell Lymphoma (DLBCL).

CONCLUSIONS

Our case illustrates that a patient with DLBCL may present with cardiac tamponade as a result of metastasis. This diagnosis, although rare, is likely to be missed, which can cause fatal complications, such as cardiac tamponade, fatal arrhythmias or sudden cardiac death.

Complex decision making in a patient with lung cancer with incidentally found fast-growing atrial mass

Atrial myxomas are typically found in the left atrium and are the most common among overall rare cardiac tumors. Herein, we describe the clinical course of a 72-year-old female with non-small cell lung adenocarcinoma found to have an atrial mass during an imaging for evaluation for lung cancer progression. Differentiating between distinct types of masses can pose a challenge to the treatment team especially in the setting of exiting malignancy. This case demonstrates the complex decision making involved in the diagnosis, and timing of intervention to remove atrial mass in patients with frailty and a fast-growing cardiac mass.

Right Atrial Mass Secondary to Breast Cancer Metastasis

We present the case of a 42-year-old female with a history of human epidermal growth factor 2 (HER2) receptor-positive breast cancer status post bilateral mastectomy with metastasis to the spine and to the brain, who underwent transesophageal echocardiography (TEE) after outpatient transthoracic echocardiography (TTE) was suggestive of right atrial thrombus in transit. TEE revealed an atrial mass with a pedunculated stalk attached to the inferior right atrium near the inferior vena cava with a necrotic center. These findings were suggestive of an endocardial metastatic mass secondary to her primary breast cancer. The pericardium is the most common site of cardiac metastasis; meanwhile, endocardial involvement is infrequent, occurring in less than 5% of all cardiac metastases. Right atrial masses may cause evidence of right heart failure and thromboembolism of the pulmonary arteries. Treatment focuses on targeted chemotherapy, radiation therapy, and interventions as indicated. In this case, following the diagnosis of a right atrial mass, the patient was discharged the same day to begin outpatient chemotherapy.

Asymptomatic mature intrapericardial teratoma in an adult: a case report of a rare condition

BACKGROUND

Benign mature teratomas are the most common type of anterior mediastinal germ cell tumor. Mature intrapericardial teratomas are generally diagnosed during infancy because of symptoms of cardiac compression. In contrast, mature adult intrapericardial teratomas are extremely rare, accounting for less than 1% of mature intrapericardial teratomas. We describe herein a case of a mature intrapericardial teratoma in an asymptomatic adult.

CASE PRESENTATION

A 52-year-old woman was found by computed tomography during a health checkup to have an anterior mediastinal mass. She was asymptomatic and hemodynamically stable with no evidence of heart failure. The preoperative provisional radiological diagnosis was a mature intrapericardial teratoma. A median sternotomy revealed an approximately 5-cm diameter protruding intrapericardial mass with a smooth surface. The mass was completely resected. Histopathological examination resulted in a diagnosis of a mature intrapericardial teratoma. The patient did well and has no evidence of recurrence 5 years after surgery.

CONCLUSIONS

Mature intrapericardial teratomas in adults are extremely rare. Given the risks of malignant transformation, rupture, compression of the heart, and infection, excision is indicated to prevent development of serious manifestations.

Successful Chemotherapy Treatment for a Tricuspid Valvular Stenosis Patient due to Right Ventricular Lymphoma

Background

This study presents a patient diagnosed with tricuspid valvular stenosis due to right ventricular lymphoma, who was treated successfully.

Case presentation

A 66-year-old man with a history of worsening shortness of breath during activity for the last three weeks sought medical attention. The patient later experienced swelling in the extremities, fluid build-up around the lungs and abdominal fluid accumulation, with no reported chest pain, fever, or weight loss. An echocardiogram found a mass in the lateral wall near the tricuspid valve of the right ventricle, leading to moderate tricuspid stenosis. The cardiac magnetic resonance imaging (MRI) revealed a lumpy, poorly defined mass that invaded the heart muscle and displayed varied enhancement after contrast administration. Suspicion arose for a malignant tumour or metastatic lesion due to its features and contrast uptake capability. A percutaneous biopsy was carried out on the mass in the right ventricle to confirm the diagnosis. The pathology report indicated a diagnosis of non-Hodgkin's lymphoma. After being diagnosed, the patient underwent chemotherapy using the R-CHOP regimen. Over time the symptoms improved, and echocardiograms revealed a decrease in the size of the tumour. After undergoing six rounds of chemotherapy, a cardiac MRI four months later showed no signs of a tumour. After that, the patient resumed their regular activities.

Conclusion

Right ventricular tumours are mostly malignant lesions and often have an inferior prognosis. Early diagnosis with imaging techniques and myocardial biopsy is necessary to deliver life-saving treatment quickly.

LEARNING POINTS

Right ventricular tumours are mostly malignant lesions and often have an inferior prognosis.Early diagnosis with imaging techniques and myocardial biopsy is necessary to deliver life-saving treatment quickly.Right ventricular lymphoma is a sporadic tumour, but the prognosis is favourable if detected in time.

Application of Three-Dimensional Printing Technology in the Perioperative Management of Cardiac Tumours: A Review and Analysis

Background

Multimodal imaging plays a crucial role in evaluating suspected cardiac tumours. In recent years, three-dimensional (3D) printing technology has continued to advance such that image-based 3D-printed models have been incorporated into the auxiliary diagnosis and treatment of cardiac tumour diseases. The purpose of this review is to analyze the existing literature on the application of 3D printing in cardiac tumour surgery to examine the current status of the application of this technology.

Methods

By searching PubMed, Cochrane, Scopus and Google Scholar, as well as other resource databases, a completed review of the available literature was performed. Effect sizes from published studies were investigated, and results are presented concerning the use of 3D surgical planning in the management of cardiac tumours.

Results

According to the reviewed literature, our study comes to the point that 3D printing is a valuable technique for planning surgery for cardiac tumours. As shown in the review report, Mucinous and sarcomatous tumours are the most commonly used tumours for 3D printing, magnetic resonance imaging (MRI) and computed tomography (CT) are the most commonly used technologies for preparing 3D printing models, the main printing technology is stereolithography, and the most used 3D modeling software is Mimics. The printing time and cost required for 3D printing are affected by factors such as the size of the type, complexity, the printed material and the 3D printing technology used. The reported research shows that 3D printing can understand the anatomy of complex tumour cases, virtual surgical simulation, as well as facilitate doctor-patient communication and clinical teaching.

Conclusions

These results show that the development of 3D printing technology has brought more accurate and safe perioperative treatment options for patients with cardiac tumours. Therefore, 3D printing technology is expected to become a routine clinical diagnosis and treatment tool for cardiac tumours.

The genetics of cardiomyocyte polyploidy

The regulation of ploidy in cardiomyocytes is a complex and tightly regulated aspect of cardiac development and function. Cardiomyocyte ploidy can range from diploid (2N) to 8N or even 16N, and these states change during key stages of development and disease progression. Polyploidization has been associated with cellular hypertrophy to support normal growth of the heart, increased contractile capacity, and improved stress tolerance in the heart. Conversely, alterations to ploidy also occur during cardiac pathogenesis of diseases, such as ischemic and non-ischemic heart failure and arrhythmia. Therefore, understanding which genes control and modulate cardiomyocyte ploidy may provide mechanistic insight underlying cardiac growth, regeneration, and disease. This chapter summarizes the current knowledge regarding the genes involved in the regulation of cardiomyocyte ploidy. We discuss genes that have been directly tested for their role in cardiomyocyte polyploidization, as well as methodologies used to identify ploidy alterations. These genes encode cell cycle regulators, transcription factors, metabolic proteins, nuclear scaffolding, and components of the sarcomere, among others. The general physiological and pathological phenotypes in the heart associated with the genetic manipulations described, and how they coincide with the respective cardiomyocyte ploidy alterations, are further discussed in this chapter. In addition to being candidates for genetic-based therapies for various cardiac maladies, these genes and their functions provide insightful evidence regarding the purpose of widespread polyploidization in cardiomyocytes.

Not everything that shines is gold, normal uptake in crista terminalis on FDG PET/CT masquerading as a tumor thrombus approaching right heart

The crista terminalis is a structure found in the right atrium, traversing along the posterolateral wall between the superior vena cava and the inferior vena cava. In some cases, the physiologic activity of F-18 FDG in crista terminalis can be mistakenly identified as a malignant mass, as was the situation in our case. Therefore, it is essential to have a thorough understanding of benign/physiologic uptake in normal anatomical structures and their variants when interpreting cardiac imaging. In this report, we present the case of a 79-year-old female patient who had recently been diagnosed with breast cancer. An 18F-FDG (fluorodeoxyglucose) PET/CT scan imaging assessment as part of staging revealed intense metabolic activity in the right atrium corresponding to prominent soft tissue. Subsequent assessment using transesophageal echocardiography (TEE) ultimately confirmed the diagnosis of a prominent crista terminalis, which is a normal anatomical variant.

A monster into the heart: an unusual presentation of cardiac leiomyosarcoma

BACKGROUND

Malignant primary cardiac tumors are infrequent and can lead to an unfavorable prognosis if not identified and treated promptly. Early detection and prompt treatment of malignant primary cardiac tumors are crucial for a better prognosis. This article presents a case of primary cardiac leiomyosarcoma and reviews the literature on this topic.

CASE PRESENTATION

Female patient that developed recurrent pericardial effusion and hemodynamic instability caused by a cardiac tumor, later identified as leiomyosarcoma. Multidisciplinary treatment was administered to the patient.

CONCLUSIONS

The initial approach to this type of pathology should include multimodality imaging to establish a prompt diagnosis leading to complete standard treatment, to minimize risks to the patient's heart function which may include resection with complete margins of the neoplasm, otherwise the prognosis may be poor.

Debulking the tricuspid valve with FlowTriever aspiration: A case series

Intracardiac masses adhering to the tricuspid valve can occur as a result of right-sided infective endocarditis, malignancy, clot formation in the right atrium, or clots-in-transit passing through the right atrium. Early surgical intervention is recommended for tricuspid valve vegetation in some patients, although open heart surgery is not always an option. Treatment options for right heart thrombi include anticoagulation, thrombolysis, surgical embolectomy, or mechanical aspiration. We present a case series of tricuspid valve debulking using aspiration with the FlowTriever System.

A Ping Pong Ball in the Left Ventricle

Diagnosing cardiac masses, especially those related to cardiac tumors, is often challenging in clinical practice. Though myxomas are the most common and well-known benign cardiac tumors, other rare and often-neglected tumors can be difficult to diagnose. In this case report, the authors describe a left ventricular cardiac mass with unique and striking imaging features.

MR imaging of primary benign cardiac tumors in the pediatric population

Primary cardiac tumors are rare in all ages, especially in children, with a reported prevalence range of 0.0017-0.28% in autopsy series. Due to their rarity, the diagnostic and therapeutic pathways reserved to them are usually described by single case reports, leading to the point where a common diagnostic protocol is imperative to obtain a differential diagnosis. The first diagnostic approach is done with transthoracic echocardiogram (TTE), due to its wide availability, low cost, absence of ionizing radiations and non-invasiveness. Several tumors are discovered incidentally and, in many cases, TTE is helpful to determine location, size and anatomical features, playing a key role in the differential diagnosis. In the last few years, cardiac magnetic resonance imaging (CMR) has had an increased role in the diagnostic pathway of pediatric cardiac masses, due to its high accuracy in characterizing mass tissue properties (especially for soft tissue), and in detecting tumor size, extent, pericardial/pleural effusion, leading to the correct diagnosis, treatment and follow-up. Therefore, nowadays, several consensus statements consider CMR as a leading imaging technique, thanks to its non-invasive tissue characterization, without the use of ionizing radiation, in an unrestricted field of view. As suggested by the most recent literature, the pediatric protocol is not so different from the adult one, adapted to the size and cardiac frequency of the patient, sometimes requiring special conditions such as free-breathing sequences and/or sedation or general anesthesia in non-cooperating patients.

Myxoma Mimic in a Patient With Acute Myeloid Leukemia

Cardiac masses are rare conditions that, depending on their size and location, can cause several cardiac and systemic symptoms. We describe a case of a 21-year-old male with a history of syphilis, pulmonary tuberculosis, and acute myeloid leukemia (AML), in whom a transthoracic echocardiogram assessment was solicited before the initiation of induction chemotherapy. The study revealed a pedunculated, highly mobile mass in the right atrium that protruded to the right ventricle. Surgical resection was performed. During surgery, tricuspid valve perforation was noted and was associated with severe tricuspid valve regurgitation. Histopathological analysis of the resected mass determined that the lesion was a cardiac thrombus.

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.

Cardiac Papillary Fibroelastoma: Atypical Presentation Mimicking Infective Endocarditis With False Positive Commensal Blood Cultures

Cardiac papillary fibroelastomas (CPFs) are rare benign cardiac neoplasms that carry a high risk of embolization if not diagnosed and managed in a timely manner. As most patients are asymptomatic, CPF may be incidentally detected on transthoracic echocardiography (TTE) when performed for other indications. Management of incidental CPF in asymptomatic patients is debatable. We report an unusual case of an incidental CPF in an asymptomatic patient admitted to the hospital for presumed infective endocarditis (IE). Two weeks following laser resection of laryngeal cancer (LC), a new pansystolic murmur was audible during a routine cardiology visit. Outpatient TTE revealed a "vegetation-like" lesion on the mitral valve (MV). Blood cultures (BC) with Gram-positive cocci in clusters (GPC) were reported within 24 hours. This prompted hospital admission for empiric antibiotics. A transesophageal echocardiogram (TEE) confirmed the lesion to be an echogenic mass attached to the MV consistent with CPF. Repeat BC, prior to empiric antibiotic initiation, were all negative. In the absence of all other signs and symptoms of IE, it was determined that the initial BC was false positive and IE was ruled out. Surgical resection was performed due to the potential risk of embolization. The pathology confirmed the diagnosis of CPF with negative tissue cultures.

A Case of Cardiac Undifferentiated Pleomorphic Sarcoma With Right Ventricular Outflow Tract Obstruction

Malignant tumors originating from the heart are extremely rare. Here, we report a case of severe right ventricular outflow tract (RVOT) stenosis in a 67 year-old woman caused by a massive intimal sarcoma that required venous-arterial extracorporeal membrane oxygenation to support systemic circulation. Surgical resection and RVOT reconstruction with tricuspid and pulmonary valve replacement were performed. The pathological diagnosis was cardiac undifferentiated pleomorphic sarcoma. Although the patient was discharged 65 days after surgery in good condition, she subsequently died from multiple metastases detected in the early phase after surgery.

Pathological Correlation of a Cardiac Mass with Multimodality Imaging

Cardiac masses are rarely encountered in clinical practice and can lead to severe hemodynamic consequences. In addition to clinical cues, noninvasive modalities can play an important role in characterization of these masses and therefore their diagnosis and management planning. Here in this case report, we describe the use of various forms of noninvasive imaging techniques to narrow the differential diagnosis and form an operative plan for a cardiac mass later identified as a benign myxoma originating from the right ventricle on histological examination.

Multimodality Imaging of Benign Primary Cardiac Tumor

Primary cardiac tumors (PCTs) are rare, with benign PCTs being relatively common in approximately 75% of all PCTs. Benign PCTs are usually asymptomatic, and they are found incidentally by imaging. Even if patients present with symptoms, they are usually nonspecific. Before the application of imaging modalities to the heart, our understanding of these tumors is limited to case reports and autopsy studies. The advent and improvement of various imaging technologies have enabled the non-invasive evaluation of benign PCTs. Although echocardiography is the most commonly used imaging examination, it is not the best method to describe the histological characteristics of tumors. At present, cardiac magnetic resonance (CMR) and cardiac computed tomography (CCT) are often used to assess benign PCTs providing detailed information on anatomical and tissue features. In fact, each imaging modality has its own advantages and disadvantages, multimodality imaging uses two or more imaging types to provide valuable complementary information. With the widespread use of multimodality imaging, these techniques play an indispensable role in the management of patients with benign PCTs by providing useful diagnostic and prognostic information to guide treatment. This article reviews the multimodality imaging characterizations of common benign PCTs.

Cardiac metastasis from small cell lung cancer origin: A case report and review of the literature

BACKGROUND

Cardiac metastasis from small cell lung cancer (SCLC) origin is rare, whereas the incidence is anticipated to increase with the extended survival rates.

CASE

We here describe a case report of a 48-year-old male patient diagnosis with SCLC in 2020. In June 2021, he resorted to hospital due to shortness of breath, no obvious changes were found in repeated echocardiography, electrocardiogram and chest computer tomography from June 2021 to September 2021. Due to the persistence of the complaints, cardiac magnetic resonance (CMR) imaging was performed in September 30th, 2021, which showed a mass in the right atrioventricular groove. The patient underwent pericardiocentesis and small cell carcinoma cells were found in the pericardial effusion, confirming the diagnosis of cardiac metastasis.

CONCLUSION

Patients with a history of SCLC who develop new cardiac symptoms of unknown etiology should undergo imaging studies such as CMR. The importance of CMR for patients with SCLC is highlighted. The literature regarding metastatic cardiac tumors is reviewed.

A Rare Case of Horseshoe Kidney With Multiple Atrial Myxomas Presenting as Cerebrovascular Accident

Myxomas are benign tumors of mesenchymal origin, containing a few pluripotent cells in the myxomatous stroma. They usually present at 30-40 years of age and are more common in females than males. These tumors mostly arise in the atria and protrude into the atrial lumen. They cause constitutional symptoms like fever and weight loss and obstructive symptoms related to outflow obstruction in the heart. Some tumors are more fragile and cause embolism and may present as stroke. Mostly sporadic but familial cases and myxomas associated with Carney syndrome (CNC) tend to be multiple. Here, we report a case of a 40-year-old female with a stroke due to embolization from multiple myxomas. She had no family history of myxoma and had no skin findings or other tumors associated with CNC. She also had an atrophied horseshoe kidney with renal failure. The association of a horseshoe kidney with myxoma is rarely reported. In an extensive literature search, we could only find only one other case. Atrial myxomas were detected while investigating the cause of stroke. Our patient gradually improved and was advised surgical removal of the myxomas, which is the treatment of choice.

An Innovative Approach to the Diagnosis of Cardiac Angiosarcoma

We present a case of a 32-year-old female presenting with shortness of breath and increasing oxygen requirements. Further imaging discovered a large mass extending circumferentially into the pericardium, cardiac wall, and chambers, involving the anterior and middle mediastinum. Direct tissue biopsy of the mass for a diagnosis was unsafe. Therefore, advanced flow cytometric analysis for tumor marker expression of the malignant effusion was used to differentiate the mass as a vascular sarcoma, consistent with cardiac angiosarcoma. Additionally, cytometric analysis for programmed cell death protein 1 (PD1), programmed death-ligand 1 (PDL1), and cytotoxic T-lymphocyte-associated antigen 4 (CTLA4) was also performed; a study seldom investigated for angiosarcomas but may have advantages over immunohistochemical analysis.

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.

Expansive intracardiac leiomyosarcoma - a combined therapeutic approach resulting in survival with complete remission. A literature review and case report

Primary cardiac sarcomas are extremely rare and often with dismal prognosis. Only a few case series and retrospective studies regarding its biological characteristics, diagnostics, and treatment were reported. The multi-modality therapeutic strategy has been discussed in the published literature, but often with contradictory results. There is thus, no consensus on the optimal therapeutic approach to date. We present the case report of the 66-year old female endangered by a large primary leiomyosarcoma expanding in the right-sided heart chambers with imminent risk of acute obstruction of blood flow. The patient was managed by urgent surgical resection. After the histological confirmation of incomplete R1 resection, the treatment was supplemented by adjuvant CT-targeted radiotherapy, resulting in extraordinary survival with complete remission over a 24-month follow-up period. Our case report aims to demonstrate a favorable result of an individually suited complex surgical and oncological treatment to support the multidisciplinary therapeutic approach to these patients. The article is supplemented by a detailed literature review providing a theoretical background and an overview of the acquired knowledge and possible strategies.

Primary and secondary cardiac tumors: clinical presentation, diagnosis, surgical treatment, and results

Cardiac tumours are some of the rarest primary tumours, while cardiac metastasis are more common yet still relatively rare. Seventy five percent of primary cardiac tumours are benign tumours. Cardiac tumours present with a range of obstructive, embolic, arrhythmic or systemic symptoms, and in many cases may present asymptomatically. The clinical presentation depends largely on the size and location of the mass. With advances in cardiac imagining and the introduction of cardiopulmonary bypass, the diagnosis and surgical treatment of these rare tumours has improved the prognosis and outlook for benign and malignant tumours. Management depends on tumour histology, size and location as well as the clinical presentation. Conservative management is reserved for small, benign tumours that can undergo regular echocardiographic follow-up. Symptomatic benign tumours are treated with surgical resection and the results are excellent. Malignant primary cardiac tumours have a poor prognosis with high rates of relapse and a median survival of 10-24 months.

Circulatory collapse secondary to intracardiac metastasis

Intracardiac metastasis is a relatively rare complication of cancer; however, it should be considered when a patient presents with a prerenal injury and circulatory collapse not responsive to medical treatment or haemofiltration as in this case.

The Rarest of the Rare: A Case of Primary Cardiac Osteosarcoma With a Review of the Literature

A 54-year-old female presented with shortness of breath and cyanosis. Work up with chest X-ray and subsequent echocardiogram revealed an intracardiac bi-atrial mass leading to emergent cardiothoracic resection. Pathology was consistent with a primary cardiac high-grade osteosarcoma. Post-resection staging positron emission tomography-computed tomography (PET-CT) showed hypermetabolic mixed lytic and sclerotic lesion of T10 concerning for metastasis. She received five cycles of adriamycin and ifosfamide chemotherapy before discontinuation due to systolic dysfunction. Nine months later, she developed a high tumor burden with progressive disease and was treated with second-line gemcitabine/docetaxel with disappointing results. She is currently on treatment with cyclophosphamide and topotecan as third-line treatment with an excellent clinico-radiographic response. Osteosarcomas are aggressive with a high incidence of recurrence and metastasis. Fewer than 50 cases of primary cardiac osteosarcomas have been reported in the literature. Even though complete resection can be achieved in some cases, long-term results are usually poor. No standard therapy has been established.

Cardiac Masses: The Role of Cardiovascular Imaging in the Differential Diagnosis

Cardiac masses are space occupying lesions within the cardiac cavities or adjacent to the pericardium. They include frequently diagnosed clinical entities such as clots and vegetations, common benign tumors such as myxomas and papillary fibroelastomas and uncommon benign or malignant primary or metastatic tumors. Given their diversity, there are no guidelines or consensus statements regarding the best diagnostic or therapeutic approach. In the past, diagnosis used to be made by the histological specimens after surgery or during the post-mortem examination. Nevertheless, evolution and increased availability of cardiovascular imaging modalities has enabled better characterization of the masses and the surrounding tissue. Transthoracic echocardiography using contrast agents can evaluate the location, the morphology and the perfusion of the mass as well as its hemodynamic effect. Transesophageal echocardiography has increased spatial and temporal resolution; hence it is superior in depicting small highly mobile masses. Cardiac magnetic resonance and cardiac computed tomography are complementary providing tissue characterization. The scope of this review is to present the role of cardiovascular imaging in the differential diagnosis of cardiac masses and to propose a step-wise diagnostic algorithm, taking into account the epidemiology and clinical presentation of the cardiac masses, as well as the availability and the incremental value of each imaging modality.

The Current Management of Cardiac Tumours: a Comprehensive Literature Review

OBJECTIVE

To understand the current evidence and guidelines behind the appropriate management of cardiac tumours.

METHODS

A comprehensive electronic literature search has been performed in major databases - PubMed, Embase, Scopus, Ovid, and Google Scholar. All articles that discussed all different forms of cardiac tumours, their clinical presentation, diagnosis, and management methods have been critically appraised in this narrative review.

RESULTS

All relevant studies have been summarized in appropriate sections within our review. Cardiac tumours are rare but can be catastrophic and life-threatening if not identified and managed on timely manner. Utilization of all the available imaging methods can be of equivocal importance, relevant to each cardiac tumour. Surgical excision is the ultimate treatment method, however histopathological results can guide the adjunct treatment.

CONCLUSION

Early detection of cardiac tumours has significant effect on planning the method of intervention. Technological advancements and increased availability of imaging modalities have enabled earlier and more accurate detection of these tumours. Novel medical therapies, recommendations for screening, and operative techniques have all contributed to overall improving knowledge of these tumours and ultimately patient outcomes.

Masses in right side of the heart: spectrum of imaging findings

Primary heart tumors are rare, benign tumors represent the majority of these. If a cardiac mass is found, the probability that it is a metastasis or a so-called “pseudo-mass” is extremely higher than a primary tumor. The detection of a heart mass during a transthoracic echocardiography (TE) is often unexpected. The TE assessment can be difficult, particularly if the mass is located at the level of the right chambers. Cardiac Computed Tomography (CCT) can be useful in anatomical evaluation and Cardiac Magnetic Resonance (CMR) for masses characterization as well. We provide an overview of right cardiac masses and their imaging futures. (www.actabiomedica.it)

Primary Cardiac Epithelioid Angiosarcoma in a Latin American Patient: Case Report and Literature Review

Cardiac angiosarcoma is a rare and clinically challenging pathology. It is a high-grade primary malignant tumor of the heart tissue that has many variants, of which the epithelioid variant is rarely present in the heart or the great vessels. As with many other cardiac tumors, it is mainly a diagnosis of exclusion and the initial diagnostic test is an echocardiogram followed by a biopsy with immunohistochemistry analysis to ascertain the type of tumor. The differential diagnosis of cardiac tumors is challenging due to the overlapping clinical manifestations with different cardiac tumors and systemic diseases. Cardiac angiosarcomas are often aggressive with a poor prognosis even with treatment. Herein, we present a case of the epithelioid variant of a cardiac angiosarcoma in addition to a thorough review of the recent literature on the clinical manifestation, diagnosis, and treatment of this type of tumors.

Small Cell Lung Cancer Invading the Left Atrium With Subsequent Malignant Embolic Stroke: A Case Report and Review of Literature

Cardiac tumors are uncommon, and the vast majority of them are metastases from extracardiac sources. Metastatic spread to the heart causes symptoms by mechanical obstruction of circulation, direct myocardial invasion, or distal embolization. We herein report a case of a 58-year-old male who presented to the hospital with multilobar intracranial embolic infarcts who was found to have small cell lung cancer (SCLC) with invasion of the left atrium and pulmonary artery resulting in malignant embolic stroke. Cerebral tumor thromboembolism from SCLC is extremely rare. This case demonstrates the thromboembolic risk associated with metastatic endoluminal cardiac tumors.

Papillary Fibroelastoma of the Ascending Aorta

Papillary fibroelastomas are rare benign primary cardiac tumors. They are typically found on valvular surfaces, most commonly, the aortic valve. In this article, we report a case of papillary fibroelastoma arising from the sinotubular junction of the ascending aorta, a rare and unusual site causing an embolic stroke.

Obstructive teratoma in the right ventricle of a newborn: a case report

BACKGROUND

A newborn was diagnosed by echocardiogram with an asymptomatic cardiac mass in the right ventricle after a systolic cardiac murmur was detected at birth.

CASE PRESENTATION

Nine days after birth, the newborn presented with three syncopal episodes and oxygen desaturation which required resuscitation. The mass induced a complete right ventricular outflow tract obstruction. The presence of a patent foramen oval and a patent ductus arteriosus explained the absence of symptoms at birth. Surgery was rapidly considered since the situation was life threatening. The tumor was successfully resected. The mass was a mature teratoma confirmed by microscopic examination, illustrated by pictures and video.

CONCLUSIONS

This case was unique because of the absence of symptoms in the first 9 days of the newborn's life even though symptoms should have mounted due to the obstruction postpartum. The delay was correlated to the closure of the patent ductus arteriosus. It is recommended that newborns with any cardiac mass be followed up regularly due to hemodynamic changes at birth.

Functional Mitral Stenosis: Imposture of Primary Cardiac Intimal Sarcoma

Cardiac intimal sarcomas are extremely rare, remarkably aggressive and least reported type of primary malignant tumors of the heart. Cardiac intimal sarcomas are encountered more commonly in the large arterial blood vessels including pulmonary artery and aorta, and are extremely rare in the heart. The mainstay of treatment is achievement of tumor-free margins with surgical resection, which is associated with improved survival. Here, we report a 66-year-old female with primary cardiac intimal sarcoma presented with functional mitral stenosis and heart failure. This case report emphasizes common presentation of a rare disease, and the significance of early diagnosis and timely intervention.

Cardiac Dedifferentiated Liposarcoma Requiring a Mitral Valve Replacement Complicated by Severe Paravalvular Leak: A Rare Case Report with Literature Review

Cardiac sarcomas have a high infiltrative and metastatic potential and are often associated with poor prognosis. These tumors are often identified incidentally by thoracic and cardiac imaging. However, when symptomatic, their presentation can differ based on the localized structural effects on the endocardium, myocardium, pericardium, and valves as well as on dynamic effects on the cardiac function. We report a case of a 61-year-old female who presented to the emergency room with recurrent chest pain, fatigue, and chronic anemia. A transthoracic echocardiogram demonstrated a left atrial mass attached to the septal wall and anterior leaflet of the mitral valve. The mass was further characterized by a transesophageal echocardiogram and cardiac MRI. The patient underwent a resection of the left atrial mass with mitral valve replacement (MVR) and atrial septal defect repair. MVR was later complicated by paravalvular leak leading to acute congestive heart failure. Tissue immune histology was consistent with dedifferentiated liposarcoma. Cardiac dedifferentiated liposarcoma is extremely rare with only few cases reported in literature. We attempt to review the clinical features, diagnosis, and management of cardiac sarcoma with great emphasis.

Pulmonary Embolism Following Incomplete Surgical Resection of a Right Ventricular Myxoma: A Case Report and Review of the Literature

Abstract

Right ventricular (RV) myxomas are extremely rare, but may have dreadful clinical sequelae including pulmonary embolism (PE). We present a case of a patient who had an RV myxoma that was attached to the tricuspid valve, and therefore could not be resected completely during surgery, and remnants of the tumor were seen on transthoracic echocardiogram during post-operative follow-up. Five months after surgery, the patient had PE, which could be due to tumor emboli or thromboemboli. Since repeat surgical resection was not feasible, the patient was started on warfarin. The patient is doing well and has had no PE recurrence over the past 20 months of follow-up. We have complemented the current case report with a comprehensive literature search and review on RV myxomas associated with PE in order to shed light on this uncommon but potentially lethal disorder. We concluded that right-sided cardiac myxomas, including RV myxomas, should be considered while dealing with PE, particularly in young patients with no risk factors, and that follow-up with echocardiography after surgery is important due to the possibility of recurrence, especially if complete resection was difficult to perform.

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Perioperative transesophageal echocardiography for non-cardiac surgery

PURPOSE

The use of transesophageal echocardiography (TEE) has evolved to include patients undergoing high-risk non-cardiac procedures and patients with significant cardiac disease undergoing non-cardiac surgery. Implementation of basic TEE education in training programs has increased across a broad spectrum of procedures in the perioperative arena. This paper describes the use of perioperative TEE in non-cardiac surgery and provides an overview of the basic TEE examination.

PRINCIPAL FINDINGS

Perioperative TEE is used to monitor hemodynamic parameters in non-cardiac procedures where there is a high risk of hemodynamic instability. Its use extends to include moderate-risk procedures for patients with significant cardiac diseases such as low ejection fraction, hypertrophic cardiomyopathy, severe valve lesions, or congenital heart disease. Vascular procedures involving the aorta, blunt trauma, and liver transplantation are all examples of procedures that may benefit from TEE. Transesophageal echocardiography examination allows assessment of volume status, ventricular function, diagnosis of gross valvular pathology and pericardial tamponade, as well as close monitoring of cardiac output, response to therapy, and the impact of ongoing surgical manipulation. In patients with unexplained and unexpected hemodynamic instability, "rescue TEE" can be used to help identify the underlying cause.

CONCLUSIONS

Perioperative TEE is emerging as a preferred tool to manage hemodynamics in high-risk procedures and in high-risk patients undergoing non-cardiac surgery. A rescue TEE examination protocol is a helpful approach for early identification of the etiology of hemodynamic instability.

Vegetation Attached to the Left Interatrial Septal Surface at the Congenital Location of the Foramen Ovale: A Rare Occurrence

BACKGROUND Non-valvular mural infective endocarditis (IE) is a rare bacterial growth on cardiac walls. Several risk factors have been reported. Echocardiography is an important diagnostic modality for diagnosing vegetation attached to the intracardiac walls. CASE REPORT We present the case of a 57-year-old man admitted with Staphylococcus aureus bacteremia due to an infected tunnelled hemodialyses catheter. Transthoracic echocardiogram did not show any abnormality, but transesophageal echocardiogram (TEE) revealed a 1.7×0.8 cm mobile echo-density attached to the surface of the interatrial septum in the left atrium, where the foramen ovale (FO) exists in utero. The patient was transferred to another facility for re-do sternotomy cardiac surgery, where these findings were confirmed intraoperatively. A biopsy of the mass was taken, which confirmed it to be a vegetation attached to the FO. CONCLUSIONS We report the first case in the literature of vegetation attached to the surface of the interatrial septum in the left atrium at the congenital location of the foramen ovale. There have been no previously reported cases in the literature with such novel imaging findings.

Cardiac Relapse of Acute Myeloid Leukemia after Allogeneic Hematopoietic Stem Cell Transplantation

Secondary or metastatic cardiac tumors are much more common than primary benign or malignant cardiac tumors. Any tumor can cause myocardial or pericardial metastasis, although isolated or combined tumor invasion of the pericardium is more common. Types of neoplasia with the highest rates of cardiac or pericardial involvement are melanoma, lung cancer, and breast and mediastinal carcinomas. Acute myeloid leukemia (AML) is the most common type of acute leukemia in adults. Initial treatment involves chemotherapy followed by consolidation treatment to reduce the risk of relapse. In high-risk patients, the treatment of choice for consolidation is hematopoietic stem cell transplantation (HSCT). Relapse of AML is the most common cause of HSCT failure. Extramedullary relapse is rare. The organs most frequently affected, called “sanctuaries,” are the testes, ovaries, and central nervous system. We present a case with extramedullary relapse in the form of a solid cardiac mass.

Cardiac Fibroelastoma versus Thrombus: Echocardiographic Evidence Can Be Misleading

We present a case of a young female with stroke symptoms who underwent valve sparing resection of a presumed fibroelastoma based on echocardiographic findings. After confirming embolic stroke, she underwent excision of the lesion, which on pathology revealed a nonbacterial thrombus. Ultimately, this led to a more extensive work-up leading to the discovery of a papillary serous ovarian carcinoma, the underlying cause of her hypercoagulable state. The initial echocardiographic findings painted the clear picture of a papillary tumor on the aortic valve which was likely the source of the emboli resulting in ischemic stroke. This unique case presentation illustrates that imaging, including echocardiography, may not always coincide with the clinical diagnosis. Thus, understanding the differential diagnoses of cardiac masses is of vital clinical significance. The distinction of fibroelastoma versus the much less common finding of aortic thrombus may lead to early diagnosis of malignancy and prevention of life threatening events due to stroke or undiagnosed disease.

Unconventional location for a cardiac lipoma: The anterior papillary muscle

Primary cardiac tumors are uncommon, and lipoma is the second most frequent benign type after myxoma. The treatment of choice is surgery, with the complete excision of the mass. Nevertheless, in the absence of symptoms and clinical signs the indication for surgery is less defined, and close follow up may be recommended. In the case we are going to report the patient was followed by periodical clinical and echographic examination, always reconsidering the possibility of treatment. <Learning objective: Cardiac lipoma is a tumor with different possible locations in the cardiac tissue and with different possible clinical patterns; in the presence of a cardiac lipoma the treatment of choice is surgery. The presence of a cardiac mass suggests investigating it with a high-resolution image examination, and to strictly follow the patient over time.>.

Paroxysmal supraventricular tachycardia as first manifestation of right atrial hemangioma during endovascular treatment of intracranial arteriovenous fistulas

We report the description of a cardiac mass occupying almost the entire right atrium in a young man who developed paroxysmal supraventricular tachycardia during endovascular treatment of intracranial arteriovenous fistulas. The mass was detected at echocardiographic examination, its tissue characteristics were defined with cardiac magnetic resonance and it was successfully surgically removed. The histopathological findings were consistent with a mixed type cavernous-capillary hemangioma of the heart. The intriguing co-existence of cardiac hemangioma and cerebral arteriovenous fistulas, to the best of our knowledge, has not been previously reported in English Literature.