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P1308 A peculiar case of an acute pulmonary embolism. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
INTRODUCTION
Cardiac tumors represent a challenging diagnosis, since the heart is an unusual site of metastasis from any malignancy.Metastatic tumors usually arise from lung, breast, renal cancer, melanomas, and lymphomas but cardiac metastization from bladder urothelial carcinoma is an extremely rare event. Here, we report the case of an 82-year-old man in whom right ventricular extension of cardiac metastization was diagnosed after a pulmonary thromboembolism.
CASE REPORT DESCRIPTION
An 82-year-old male was admitted to our hospital with a history of cough with streaky hemoptysis, fever and anorexia for 2 weeks, and breathlessness on exertion for 2 day. He had a history of bladder urothelial carcinoma 3 months ago, with extensive areas of epidermoid differentiation, treated only surgically with cystectomy. On physical examination, he was afebrile with a blood pressure of 135/70, tachycardic at 115beats/min, and his respiratory rate was 26breaths/min. The room air oxygen saturation was 90%, and arterial blood gas analysis revealed hypoxemia with an elevated alveolo-arterial oxygen gradient. The blood test revealed a normocytic normochromic anemia and an elevated levels of D-dimer. The echocardiogram revealed a pediculated and mobile mass attached to the apex of the right ventricle. A CT pulmonary angiography was performed and found an acute and bilateral pulmonary thromboembolism, being the patient immediately hypocoagulated. It was also performed a cardiac MRI (with and without contrast) that showed a large mass in the RV. It was arising from the RV free wall and was occupying almost half of the RV (mid and apical cavity). It had irregular edges with intermediate enhancement on T1 images and is hyperintense on T2 stir images. There was some evidence of contrast uptake on T1 weighted contrast images. It did not seem to have a significant fatty component on T1 weighted images with fat saturation. The cardiac MRI features were consistent with tumorous involvement of the RV. As part of the work for primary cancer, a colonoscopy was performed which also showed the presence of metastases in the proximal sigmoid colon from the bladder urothelial carcinoma. During hospitalization, the echocardiogram was repeated, showing an increase in the mass previously described, extending to the trunk of the pulmonary artery. Soon after, our patient died suddenly after an episode of sudden dyspnea and hemodynamic instability.
CONCLUSION
We experienced a very uncommon case of a metastatic cardiac tumor from urothelial carcinoma. To the best of our knowledge, only a small number of cases were reported and the reason for the rarity of cardiac metastasis from urothelial carcinoma is unclear. Although the echocardiography has become the gold standard for the diagnosis of intracardiac masses, cardiac MRI plays an important role in the evaluation of cardiac masses of non-neoplastic and neoplastic origin, allowing a comprehensive characterization of such lesions.
Abstract P1308 Figure. pediculated and mobile mass (20x56mm) at
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P226 Caseous calcification of the mitral annulus: a silent cause of intracardiac mass. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
INTRODUCTION
Caseous calcification of the mitral annulus (CCMA) is a very rare variant of mitral annular calcification with a central liquefaction necrosis, being an uncommon echocardiographic finding (0.5 to 1%) which may be mistaken for an intracardiac tumor, thrombus or vegetation. This chronic degenerative process can occurs at advanced ages, particularly in women, and patients with hypertension, chronic renal failure or calcium metabolism abnormalities. Since patients often remain asymptomatic, conservative treatment for this lesion is generally sufficient.
CASE REPORT
DESCRIPTION
We report a case of an 86-year-old female with a known history of hypertension and diabetes, who was referred to our department in order to investigate the diagnosis of an intracardiac mass visualized through a routine transthoracic echocardiography. She reported effort dyspnea, but refused to have other cardiovascular symptoms.
In order to study this intracardiac mass, the patient was submitted to a transthoracic echocardiogram that showed a rounded mass of 16 × 22 mm in the anterior mitral annulus, mainly in P1 scallop, not causing valve stenosis and with a mild mitral regurgitation. This prompted the need for transesophageal echocardiography which revealed a spheroid mass of heterogeneous content with calcification points, regular edges and with faint central echo-lucent area without acoustic shadowing, attached to the anterior mitral valve leaflet. No communication with any cardiac chamber could be detected. The mass did not determine any restriction to the opening of mitral valve cusps. A cardiac MRI was requested to complete the diagnostic evaluation revealing that the lesion was located at the base of the anterior leaflet. In the T1 and T2 sequences the mass was hypointense, whereas in the perfusion sequence, no contrast penetration was detected in the mass and in the late enhancement. These findings, as well as the presence of a calcified envelope in the cardiac computed tomography scan, confirmed the suspicion of caseous calcification of the mitral annulus.
DISCUSSION
AND CONCLUSIONS
We present an unusual case of caseous calcification of the mitral annulus in which the multi-modal approach was crucial to confirme the diagnosis. Although transthoracic echocardiography can be sensitive in the diagnosis of this entity, the diagnosis may sometimes still be inconclusive. Thus, multi-modality with transesophageal echocardiography, cardiac MRI or CT can lead to a definitive diagnosis, avoiding an mistaken diagnosis with the need of a surgical approach. Since this pathology is most frequently detected in asymptomatic patients, the patients should be treated medically and monitored clinically and echocardiographically for an early recognition of possible complications.
Abstract P226 Figure. Caseous calcification of mitral annulus
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