Differential Diagnosis Of Cardiac Masses Research Articles

Prominent crista terminalis mimicking a right atrial mass: a systematic literature review and meta-analysis.

The crista terminalis is an anatomical structure localized on the posterolateral wall of the right atrium (RA). We performed a systematic review of the literature and meta-analysis concerning cases of unusual prominent crista terminalis mimicking RA mass. Moreover, we described the differential diagnosis of cardiac masses with the use of echocardiography, computed tomography, and cardiac magnetic resonance (CMR). We also emphasize the potential importance of this structure in electrophysiological procedures, including its role in exaggerated arrhythmias. Prominent crista terminalis may be a potential obstacle during invasive cardiac procedures or catheter ablation target. In analyzed cases, the crista terminalis was often erroneously interpreted as pathologic and at first confused with a thrombus or tumor during transthoracic echocardiography examination. The correct final diagnoses were mostly made with used transesophageal echocardiography or CMR. The most important imaging findings suggestive of prominent crista terminalis rather than tumor were a similar echogenicity/intensity with adjacent myocardium, the location on posterolateral wall of the RA, the phasic change in size, and no enhancement after contrast injection. We describe up to date and detailed imaging features for the differential diagnostics of selected intracardiac masses using various imaging techniques, including multimodality cardiac imaging. Familiarity with the anatomy and the imaging findings of the prominent crista terminalis will reduce misdiagnosis and avoid additional tests and unwarranted clinical interventions, while in patients considered for invasive cardiac procedures it might increase their efficacy and safety.

1016 CARDIAC MAGNETIC RESONANCE IMAGING IN DIFFERENTIAL DIAGNOSIS OF CARDIAC MASSES

Abstract Background Differential diagnosis of cardiac masses represents a challenging issue with important implications for therapeutic management and patient's prognosis. Cardiac Magnetic Resonance (CMR) is a non-invasive imaging technique used to characterize morphologic and functional features of masses. Integration of these information can lead to an accurate diagnosis. Purpose To evaluate the diagnostic role of CMR in defining the nature of cardiac masses. Methods One hundred-fourteen patients with cardiac masses evaluated with CMR were enrolled. All masses had histological certainty. CMR sequences allowed a qualitative morphologic description as well as tissue characterization. Evaluation of masses morphology included localization, size and borders assessment, detection of potential multiple lesions and pericardial effusion. Tissue characterization resulted from an estimation of contrast enhancement - early gadolinium enhancement (EGE) and late gadolinium enhancement (LGE) sequences - and tissue homogeneity in T1 and T2 weighted acquisitions. The descriptive analysis was carried out by comparing benign vs malignant lesions as well as dividing patients into 4 subgroups: primitive benign tumours, primitive malignant tumours, metastatic tumours and pseudotumours. Results The descriptive analysis of morphologic features showed that diameter > 50 mm, invasion of surrounding planes, irregular margins and presence of pericardial effusion were able to predict malignancy (p < 0.001). As for tissue characteristics, heterogeneous signal intensity - independently from T1 and T2 weighted acquisitions - and EGE were more common in malignant lesions (p <0.001). When analysing the four subgroups, CMR features did not discriminate between primitive malignant masses and metastasis. Conversely, hyperintensity signal in T2 w-TSE, EGE and heterogeneity after gadolinium enhancement were more common in benign primitive lesions compared to pseudotumours. Furthermore, using classification and regression tree (CART) analysis, we developed an algorithm to differentiate masses: invasion of surrounding planes was a common characteristic of malignancy and identifies itself malignant tumours. In the absence of invasive features, gadolinium enhancement was evaluated: the lack of contrast uptake was able to increase the probability of a pseudotumour. Last step of decision algorithm included ejection fraction assessment to discriminate between benign tumours: a reduced ejection fraction increased the probability of pseudotumour diagnosis and reduced the probability of primary benign tumour diagnosis. Conclusions Cardiac magnetic resonance is a very powerful diagnostic tool for differential diagnosis of cardiac masses as it correctly addresses malignancy. Furthermore, an accurate evaluation of the several CMR features may discriminate primary benign masses and pseudotumours.

Cardiac magnetic resonance imaging in differential diagnosis of cardiac masses

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): S. Orsola Hospital Background  Differential diagnosis of cardiac masses represents a challenging issue with important implications for therapeutic management and patient’s prognosis. Cardiac Magnetic Resonance (CMR) is a non-invasive imaging technique used to characterize morphologic and functional features of masses. Integration of these information can lead an accurate diagnosis. Purpose  To evaluate the diagnostic role of CMR in defining the nature of cardiac masses. Methods : Ninety-three patients with cardiac masses evaluated with CMR were enrolled. All masses had histological certainty. CMR sequences allowed a qualitative morphologic description as well as tissue characterization. Evaluation of masses morphology included localization, size and borders assessment, detection of potential multiple lesions and pericardial effusion. Tissue characterization resulted from an estimation of contrast enhancement - early gadolinium enhancement (EGE) and late gadolinium enhancement (LGE) sequences - and tissue homogeneity in T1 and T2 weighted acquisitions. The descriptive analysis was carried out by comparing benign vs malignant lesions as well as dividing patients into 4 subgroups: primitive benign tumours, primitive malignant tumours, metastatic tumours and pseudotumours.  Results  The descriptive analysis of the morphologic features showed that diameter > 50mm, invasion of surrounding planes, irregular margins and presence of pericardial effusion were able to predict malignancy (p < 0.001). As for tissue characteristics, heterogeneous signal intensity - independently from T1 and T2 weighted acquisitions - and EGE were more common in malignant lesions (p <0.001). When analysing the four subgroups, CMR features did not discriminate between primitive malignant masses and metastasis. Conversely, hyperintensity signal and EGE were able to distinguish benign primitive lesions from pseudotumors (p = 0.002).  Furthermore, using classification and regression tree (CART) analysis, we developed an algorithm to differentiate masses: invasion of surrounding planes was a common characteristic of malignancy and identifies itself malignant tumors. In the absence of invasive features, gadolinium enhancement was evaluated: the lack of contrast uptake was able to exclude a pseudotumor diagnosis and reduced the probability of a primary benign tumor.  Conclusions Cardiac magnetic resonance is a very powerful diagnostic tool for differential diagnosis of cardiac masses as it correctly addresses malignancy. Furthermore, an accurate evaluation of the several CMR features, may discriminate primary benign masses and pseudotumours. Abstract Figure. Benign and malignant cardiac masses

Cardiac Myeloid Sarcoma: Multimodal Imaging and Histopathologic Findings.

Supplemental material is available for this article.

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 diagnostic performance of magnetic resonance imaging for differentiating the nature of cardiac masses: A systematic review protocol.

Cardiac masses are rare, but lead to high risk of stroke and death. Because of the different treatment methods, it is significant for clinicians to differentiate the nature of masses. Cardiac magnetic resonance (CMR) imaging has high intrinsic soft-tissue contrast and high spatial and temporal resolution and can provide evidence for differential diagnosis of cardiac masses. However, there is no evidence-based conclusion as to its accuracy. Therefore, the purpose of our study is to perform a systematic review on this issue and provide useful information for clinical diagnosis and treatment. We will perform a systematic search in EMBASE, Cochrane Library, PubMed and Web of Science for diagnostic studies using CMR to detect cardiac masses from inception to October, 2019. Two authors will independently screen titles and abstracts for relevance, review full texts for inclusion and conduct detail data extraction. The methodological quality will be assessed using the QUADAS-2 tool. If pooling is possible, we will use bivariate model for diagnostic meta-analysis to estimate summary sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of CMR, as well as different sequences of CMR. Estimates of sensitivity and specificity from each study will be plotted in summary receive operating curve space and forest plots will be constructed for visual examination of variation in test accuracy. If enough studies are available, we will conduct sensitivity analysis and subgroup analysis. The results of this systematic review and meta-analysis will be published in a peer-reviewed journal. To our knowledge, this will be the first systematic review on the accuracy of CMR in the differential diagnosis of cardiac masses. This study will provide evidence and data to form a comprehensive understanding of the clinical value of CMR for cardiac masses patients. Ethics approval and patient consent are not required, as this study is a systematic review. CRD42019137800.

Differential diagnosis of cardiac mass: Thrombi? Or Tumor?

Differential diagnosis of cardiac mass: Thrombi? Or Tumor?

A rare presentation of a soft tissue sarcoma metastasized to the left ventricle

Primary cardiac tumors are a rare diagnosis with a reported incidence of 0.001%-0.1% in the general population. They provide adiagnostic challenge as the patients may be asymptomatic or have a wide variety of symptoms. Because of this, cardiac tumorsare often discovered incidentally by imaging modalities or during surgery. Secondary tumors that metastasize to the heart aremore common with an incidence of 0.7%-3.5% in the general population and up to 9.1% in patients with known malignancies. Metastatic tumors most frequently involve the pericardium followed by the epicardium and myocardium. Intracavitary andendocardial metastasis has been rarely described in the literature. We present a case of a patient who had a known soft tissuesarcoma with widespread metastases who presented because of dyspnea. In her workup, a transthoracic echocardiogram revealedan intracavitary mass attached to the left ventricular side of the interventricular septum presumed to be a sarcoma. In ourcomprehensive literature search, a sarcoma has rarely been reported in the left ventricle. We have found that sarcomas that dometastasize to the myocardium often are highly differentiated and carry a poor prognosis. A cardiac tumor may be detected bytransthoracic echocardiogram, transesophageal echocardiogram, magnetic resonance imaging (MRI), computed tomography (CT) or PET scan. The transthoracic echocardiogram is the preferred modality given its availability, cost and portability. Additionalimaging modalities such as contrast echocardiography and MRI can help differentiate cardiac tumors from other cardiac massessuch as thombi or vegetations. Because of the inability to rely on physical signs and symptoms, there must be a high degree ofsuspicion when a patient with known metastatic disease presents with cardiac complaints. It is important for clinicians to beaware of how different imaging modalities can help guide their differential diagnosis of cardiac masses.

Expecting the unexpected: right atrial mass in a transplant patient.

We present a 71‐year‐old male, who had had a heart transplantation 24 years prior, who came to our clinic with a low‐grade fever and a new II/VI holosystolic murmur. Echocardiography showed a large mass in the right atrium with attachment near the junction of the right atrium and superior vena cava. The patient was taken to the operating room for resection of the mass. Microscopic evaluation was consistent with thrombus. Differential diagnosis of cardiac masses after cardiac transplant includes tumour, thrombus, and vegetation. Final diagnosis can be challenging; multimodality imaging and biopsy or resection often are required for final diagnosis.

Usefulness of Contrast Perfusion Echocardiography for Differential Diagnosis of Cardiac Masses

The aim of this study was to assess the usefulness of contrast perfusion echocardiography in the differential diagnosis of different types of cardiac masses. Conventional echocardiography and contrast perfusion echocardiography were performed in 72 patients with cardiac masses. The degree of contrast enhancement of the mass and an adjacent section of myocardium after injection of contrast agent was determined by visual inspection and quantitative time–signal intensity curve analysis. The difference in maximal steady-state pixel intensity between the mass and the adjacent myocardium (ΔAmass–myocardium) was calculated. All masses had a pathologic diagnosis or resolved after anticoagulation. All 16 cardiac masses without enhancement on visual inspection were confirmed to be cardiac thrombi. Twenty-four masses with incomplete enhancement on visual inspection were recognized as benign tumors with validation methods. Of the 32 cardiac masses with complete enhancement, 30 were confirmed as malignant tumors and two as benign tumors with validation methods. The sensitivity and specificity of ΔAmass–myocardium in differentiating thrombi from tumors were 93% and 100%, respectively, and 100% and 97% in differentiating malignant tumors from benign tumors and thrombi. Both visual and quantitative assessment of degree of enhancement of cardiac masses in relation to the adjacent myocardium during contrast perfusion echocardiography had high diagnostic accuracy for differentiation of a thrombus from a tumor or a benign tumor from a malignant tumor.

Left atrial myxoma development after radiofrequency ablation of an atrial flutter substrate

A 51-year-old man developed symptoms (palpitations) related to a large left atrial mass attached to interatrial septum discovered by trans-thoracic heart ultrasonography. Six months earlier this patient had undergone radiofrequency ablation (RFA) of an atrial flutter substrate. The left atrial mass was removed surgically using cardiopulmonary bypass with disappearance of symptoms. A post-operative diagnosis of atrial myxoma was made. The present case shows that a big left-atrial tumor could manifest with only mild unspecific symptoms such as palpitations. It is not clear whether the development of myxomas could be related to RFA or occurrence of heart tumors after RFA (already reported in medical literature) or whether it could be just chance without a causal link with ablation procedures.<Learning objective: It is essential to consider myxoma in the differential diagnosis of cardiac masses identified in patients after radiofrequency ablation since some cases of myxoma development after radiofrequency ablation have recently been described in the literature. Transthoracic echocardiography is a precise technique in the evaluation of cardiac masses, but a high index of clinical suspicion is necessary in order to define intracardiac pathologies that could be missed for unspecific symptoms of presentation.>

Value of CMR for the Differential Diagnosis of Cardiac Masses

ObjectivesThe goal of this study was to evaluate the diagnostic value of CMR features for the differential diagnosis of cardiac masses. BackgroundDifferentiation of cardiac tumors and thrombi and differentiation of benign from malignant cardiac neoplasms is often challenging but important in clinical practice. Studies assessing the value of cardiac magnetic resonance (CMR) in this regard are scarce. MethodsWe reviewed the CMR scans of patients with a definite cardiac thrombus or tumor. Mass characteristics on cine, T1-weighted turbo spin echo (T1w-TSE) and T2-weighted turbo spin echo (T2w-TSE), contrast first-pass perfusion (FPP), post-contrast inversion time (TI) scout, and late gadolinium enhancement (LGE) sequences were analyzed. ResultsThere were 84 thrombi, 17 benign tumors, and 25 malignant tumors in 116 patients. Morphologically, thrombi were smaller (median area 1.6 vs. 8.5 cm2; p < 0.0001), more homogeneous (99% vs. 46%; p < 0.0001), and less mobile (13% vs. 33%; p = 0.007) than tumors. Hyperintensity compared with normal myocardium on T2w-TSE, FPP, and LGE were more common in tumors than in thrombi (85% vs. 42%, 70% vs. 4%, and 71% vs. 5%, respectively; all p < 0.0001). A pattern of hyperintensity/isointensity (compared with normal myocardium) with short TI and hypointensity with long TI was very frequent in thrombi (94%), rare in tumors (2%), and had the highest accuracy (95%) for the differentiation of both entities. Regarding the characterization of neoplastic masses, malignant tumors were larger (median area 11.9 vs. 6.3 cm2; p = 0.006) and more frequently exhibited FPP (84% vs. 47%; p = 0.03) and LGE (92% vs. 41%; p = 0.001). The ability of CMR features to distinguish benign from malignant neoplasms was moderate, with LGE showing the highest accuracy (79%). ConclusionsCMR features demonstrated excellent accuracy for the differentiation of cardiac thrombi from tumors and can be helpful for the distinction of benign versus malignant neoplasms.

Nonconstrictive epicarditis mimicking a cardiac mass in a 71-year-old Caucasian man: a case report and review of the literature

IntroductionIsolated cases of epicarditis are rare. Thus far, all have occurred with constrictive physiology as most cases involve both parietal and visceral pericardium. We report the first case of asymptomatic epicarditis that involved only the visceral pericardium presenting without constrictive physiology.Case presentationA 71-year-old male with a history of atrial fibrillation, coronary artery disease, pericardial effusion, type-2 diabetes and hypothyroidism presented with 5 weeks of fatigue and 1 day of dizziness. Physical examination was significant for pallor and tachycardia. Laboratory analysis revealed a hemoglobin count of 7.2 g/dl and iron deficiency anemia. The patient was transfused and evaluated by endoscopic ultrasound. A polypoid mass in the gastric cardia was found and later diagnosed as gastric adenocarcinoma (staged as T1N0M0). The pericardial effusion was evaluated with transthoracic echocardiography which showed a 2.0 × 2.7 cm mass associated with the right atrium. Transesophageal echocardiography confirmed the mass but did not reveal constrictive physiology. Whole-body contrast computed tomography failed to demonstrate metastatic disease. Biopsy of the cardiac mass revealed epicarditis without parietal pericardium involvement. Partial gastrectomy was performed to remove the gastric adenocarcinoma.ConclusionThis is the first reported case of asymptomatic epicarditis. Our case was especially unusual because the epicarditis presented as an incidental cardiac mass. The clinical picture was complicated due to the concomitant presence of gastric adenocarcinoma and chronic pericardial effusion. This case demonstrates that epicarditis should be considered in the differential diagnosis of cardiac masses.

A rare presentation of previous tuberculous infection: Constrictive pericarditis and cardiac tuberculoma

In this case report, we present a case of tuberculous constrictive pericarditis, and demonstrate large calcified pericardial tuberculomas, which is an extremely rare condition. Pericardial tuberculoma should be included in the differential diagnosis of cardiac masses.

AJR Teaching File: Right Ventricular Mass Presenting with a Heart Murmur

Case History A 61-year-old woman has had hypertension for 5 years. At a routine follow-up visit, a new cardiac murmur is identified. Cardiac sonography shows a mass in the right ventricle, and the patient is sent for cardiac MRI for further characterization. Radiologic Description The images show a mass involving the right ventricular free wall just distal to the tricuspid valve (Fig. 1A). On the double inversion recovery images, the mass has smooth margins and relatively homogeneous intermediate signal intensity centrally and slightly higher signal intensity peripherally (Figs. 1B-1D). The signal intensity is lower than that of fat but slightly higher than that of myocardium. There is no pedunculation into the ventricular cavity. The pericardium is not visible adjacent to the mass but can be identified adjacent to the right ventricular wall. No pericardial effusion is seen. Differential Diagnosis The differential diagnosis of cardiac masses includes thrombus as well as inflammatory and neoplastic entities. Inflammatory masses include abscesses from tuberculosis and from various bacteria, fungi, and parasites. Tumors of the heart include myxomas, lipomas, teratomas, ectopic thyroid, metastases, and sarcomas. Diagnosis The final pathologic diagnosis in this patient is ectopic thyroid tissue involving the heart (struma cordis). No involvement of the interventricular septum was found. Commentary Ectopic thyroid tissue may occur in any location along an axis from the base of the tongue to the diaphragm. During the third embryologic week, the thyroid begins to develop from a diverticulum of the foramen cecum in the region of the primitive craniofacial primordium [1]. This endodermal thyroid primordium is tubular until the sixth embryologic week, after which it becomes solid. At this time, under normal circumstances the distal end divides into two lobes and becomes the primitive thyroid gland [2]. The cephalad end is in contact with tissue that subsequently becomes the lower face and base of the tongue. The caudal end of the tube is in close proximity to the bulbous cordis that subsequently develops into the heart. Failure of these tissues to separate normally results in small islands of thyroid tissue remaining in the developing structures. Ectopic tissue is most commonly found at the base of the tongue followed, in descending order, by the submandibular region, cervical lymph nodes, larynx, trachea, esophagus, mediastinum, diaphragm, and heart [3]. Ninety-one percent of patients with ectopic thyroid of the heart have involvement of the right heart; only two patients have been reported with left heart involvement [1, 4]. The mass usually involves the interventricular septum but may extend to the free wall at or near the base of the heart [2].

Differential diagnosis of cardiac masses using contrast echocardiographic perfusion imaging

Differential diagnosis of cardiac masses using contrast echocardiographic perfusion imaging

Differential diagnosis of cardiac masses using contrast echocardiographic perfusion imaging

ObjectivesWe investigated the usefulness of echocardiographic contrast perfusion imaging in differentiating cardiac masses. BackgroundTwo-dimensional echocardiography is the primary diagnostic modality for cardiac masses. However, differentiation between the different types of cardiac masses may be difficult at times. We hypothesized that echocardiographic contrast perfusion imaging would differentiate the neo-vascularization of malignancies from the avascularity of thrombi and the sparse vascularity of stromal tumors. MethodsSixteen patients with cardiac masses underwent power-modulation imaging after echocardiographic intravenous contrast administration. Pixel intensities in the mass and an adjacent section of myocardium were analyzed visually and by dedicated software. All masses had a pathologic diagnosis or resolved after anticoagulation. In a subset of patients, video-intensity curves of contrast replenishment in the mass and myocardium over time were generated. The post-impulse steady-state pixel intensity (A) and initial rate of contrast replenishment after impulse (β) were compared with an index of blood vessel area on pathology. ResultsIn seven of 16 patients, contrast enhancement resulted in greater pixel intensity in the mass than in the adjacent myocardium. All of these masses were classified pathologically as malignant (n = 6) or benign and vascular (n = 1). Nine masses demonstrated decreased pixel intensity, compared with the myocardium, and were diagnosed pathologically as myxomas (n = 2) or thrombi (n = 5), or they resolved with anticoagulation (n = 2). For the subset of patients, β correlated with the vessel area index (r = 0.60). ConclusionsEchocardiographic contrast perfusion imaging aids in the differentiation of cardiac masses. Compared with the adjacent myocardium, malignant and vascular tumors hyper-enhanced, whereas stromal tumors and thrombi hypo-enhanced.