Utility of Intracardiac Echocardiography to Biopsy Cardiac Tumors

Abstract

<h3>Introduction</h3> Primary cardiac tumors are extremely rare and associated with poor prognosis, mainly due to its nonspecific symptoms and delayed diagnosis. Tissue diagnosis is the gold standard which often requires open-chest procedures, which itself has a high rate of complications. Alternatives include emerging utilization of intracardiac echocardiography (ICE) - guided biopsy which commonly used for atrial septal closure and advanced electrophysiology procedures, but can be ideally suited for imaging right heart structures. <h3>Case Report</h3> A 62-year-old female with history of left forearm peripheral sheath sarcoma with transhumeral amputation, initially presented for post-MVA care where the CT chest revealed two lung nodules of 1 cm. She was discharged in stable condition and presented a month later for palpitations and diffuse abdominal pain. A repeat chest CT revealed a 5 × 4 c.m. right atrial mass with large pericardial effusion. Pericardiocentesis of 500 cc fluid had negative cytology and TTE showed right atrial free wall mass extending into the tricuspid annulus and into the right atrial cavity. Patient was referred to us for further diagnostic management given the complexity of the cardiac mass. She underwent intracardiac echocardiography with right femoral vein access under local anesthesia. The ICE catheter was advanced through the 8 French sheaths and key images were obtained of the right atrial mass to guide bioptome targeting. A 1.85mm/2.46 mm3 Procure bioptome was advanced under direct fluoroscopic guidance into the right atrium and 3 right ventricular endomyocardial biopsy samples were obtained. Patient tolerated the procedure well without any immediate postoperative complications. The biopsy results showed tissue composed of spindle cells with hyperchromatic pleomorphic nuclei and high mitotic ratio (score 3), changes that are consistent with unclassified high-grade sarcoma. However, patient passed away due to disease progression over the course of the next few months. <h3>Summary</h3> In our study, we demonstrated the feasibility of utilizing ICE for intracardiac mass biopsy on the right side of the heart. It is an innovative and well-described procedure for intracardiac mass that avoids usage of general anesthesia, avoids radiation exposure to the patients and the physicians, and decreases the complications rate as compared to alternate options such as open-chest procedures.