Cardiac Masses Discovered by Echocardiogram; What to Do Next?

Abstract

Cardiac tumors are rare conditions, typically diagnosed on autopsy, but with the advancement of imaging techniques they are now encountered more frequently in clinical practice. Echocardiography is often the initial method of investigation for cardiac masses and provides a quick and valuable springboard for their characterization. While some cardiac masses can be readily identified by echocardiography alone, several require incorporation of multiple data points to reach diagnostic certainty. Herein, we will provide an overview of the main clinical, diagnostic, and therapeutic characteristics of cardiac masses within the framework of their location.

Keywords: Cardiac computed tomography; Cardiac magnetic resonance; Cardiac masses; Cardiac tumors; Echocardiography; Multimodality imaging; Myxoma; NBTE; Papillary fibroelastoma; Primary tumors.

Graphical abstract

Figure 1

73-year-old man, incidental finding of a PFE on echo done for dyspnea and hypertension. (a) TEE 2D image of a PFE on P2 segment of the posterior leaflet of mitral valve (MV). (b) 3D of PFE measured 10 × 10 mm. Abbreviations: 2D, 2-dimensional; 3D, 3-dimensional; PFE, papillary fibroelastoma; TEE, transesophageal echocardiography.

Figure 2

73-year-old man, incidental finding of a PFE on echocardiography done for dyspnea and hypertension. (a) PFE on sterile paper, (b) Surgical specimen suspended in saline which brings out the characteristic fronds classic of PFE. Abbreviation: PFE, papillary fibroelastoma.

Figure 3

Microscopic view of PFE. (a) Fibromyxoid frond (H&E, low power). (b) Fibromyxoid frond (H&E, high power) demonstrates the individual fronds surrounded by a single layer of endothelium. Abbreviation: PFE, papillary fibroelastoma.

Figure 4

PFE in a left atrial appendage. (a) 2-dimensional, x-plane view left atrial appendage (∗) with PFE (arrow). (b) 3-dimensional, x-plane view left atrial appendage (∗) with PFE (arrow). Abbreviation: PFE, papillary fibroelastoma.

Figure 5

CCT of PFE. (a) Standard imaging showing a PFE on a stalk attached to the aortic side of the aortic valve. (b) Close up valvular anatomy. (c) 3D reconstruction with 3D printing to plan for surgical removal. Abbreviations: 3D, 3-dimensional; CCT, cardiac computed tomography; PFE, papillary fibroelastoma.

Figure 6

Management of patient with clinically high suspicion of PFE. Abbreviations: PFE, papillary fibroelastoma; SBE, subacute bacterial endocarditis; SLE, systemic lupus erythematosus; STS, Society of Thoracic Surgery.

Figure 7

Pathology of Lambl excrescences. (a) Gross specimen of Lambl excrescences on aortic valve closure margin and leaflet edges, (b) Fibroelastic fronds, surrounded by a single cell layer of endothelium. Abbreviations: H & E stain, hematoxylin and eosin; VVG stain, Verhoeff–Van Gieson stain.

Figure 8

Lambl excrescences examples on the aortic valve (AV). (a) TEE mid esophageal view at 129 degrees of Lambl (arrow) on LVOT side AV. (b) 3D of the aortic valve showing 3 Lambl excrescences (arrows) on the aortic side of the AV. Abbreviations: 3D, 3-dimensional; LVOT, left ventricular outflow tract; TEE, transesophageal echocardiography.

Figure 9

Pathologic specimens of degenerative strands and fenestrations aortic valve (AV). (a) Pathologic origin of degenerative strands and fenestrations due to the wear and tear of the valve structures. (b) 3D echo of aortic valve (AV) and fenestration (arrows) correlated with pathology. (c) Gross surgical specimen of the fenestrated aortic valve (arrow). Abbreviation: 3D, 3-dimensional.

Figure 10

Nonbacterial thrombotic endocarditis. (a) NBTE arising in the context of antiphospholipid syndrome affecting the mitral valve (MV) in diastolic kissing lesions is well visualized. (b) In systole the MV kissing lesions more difficult. (c) Associated mitral regurgitation (MR). (d) Patient with pancreatic cancer and presenting with a stroke TEE zoom view of the aortic valve (AV) in short axis during systole with thickened midportion of all 3 leaflets (arrows) can be subtle and confused with nodules of Arantius. (e) Showing the AV in systole, short axis view, measurements of the left and right aortic cusp NBTE vegetations (arrows). (f) Showing the AV in systole, long-axis view, measurements of the left and right aortic cusp NBTE vegetations (arrows). Abbreviations: NBTE, nonbacterial thrombotic endocarditis; TEE, transesophageal echocardiography.

Figure 11

Nonbacterial thrombotic endocarditis in 61-year-old women with rheumatoid arthritis and progressive dyspnea on exertion echo showed mixed mitral regurgitation and stenosis. (a) TEE of zoom view of the mitral valve (MV) systole with bulky kissing lesions (arrow) well visualized. (b) Color flow of the mitral regurgitation (MR). (c) Diastolic mean gradient 13 mmHg. (d) MV in diastole showing kissing lesions (arrows). (e) Surgeons view showing bulky red thrombotic noninfectious vegetations (V) around MV orifice. (f) Extracted gross pathology of MV with the nonbacterial thrombotic vegetations. Abbreviation: TEE, transesophageal echocardiography.

Figure 12

Blood cyst (BC). (a) Blood cyst (arrow) on the anterior leaflet of the mitral valve (MV) ventricular side; (b) Blood cyst (arrow) highlighted by echo contrast, showing bubbles on the inside of the cystic cavity; (c) Surgical removal of a tricuspid valve (TV) blood cyst.

Figure 13

Cardiac hemangioma. (a) Mitral valve (MV) cardiac hemangioma (arrow) near the base of the anterior leaflet. (b) Zoom view of MV. (c) Pathology of cavernous hemangioma forming a 0.7 × 0.5 × 0.5 cm nodule.

Figure 14

Cardiac myxoma pathology. (a) Carney faces: typical lentigines along the vermilion border of lips (top panel) and eye lids (bottom panel) in 2 patients with Carney complex. (b and c) Transesophageal echo images from a patient with Carney complex with 2 cardiac myxoma (CM). (b) Mid-esophageal view in long axis showing myxoma along the anterior septum left ventricle (arrow). (c) Transgastric view of myxoma on right ventricular septum (arrow).

Figure 15

Typical sporadic cardiac myxoma left atrial (LA) cardiac myxoma (CM), papillary morphology in a 55-year-old woman who presented with cough and dyspnea. Transesophageal echo (a) LA CM (green arrow) attached to the atrial septum (blue arrow) demonstrating prolapse through mitral valve into left ventricle during diastole. (b) Surgical view of the LA myxoma. (c) Gross pathology of CM.

Figure 16

Atypically located cardiac myxoma. (a) Intraoperative 2D TEE bicaval view of cardiac myxoma (CM) at the junction of the superior vena cava (SVC) and right atrium (RA) smooth morphology. (b) 3D zoom demonstration of smooth morphological CM. Abbreviations: 2D, 2-dimensional; 3D, 3-dimensional; TEE, transesophageal echocardiography.

Figure 17

Rhabdomyoma in a one-year-old boy. (a) Parasternal long-axis view, rhabdomyoma (arrows) in the left atrium (LA) and left ventricular outflow tract (LVOT). (b) Left ventricular (LV) apical four-chamber view congenital format (apex down) showing left ventricular lateral wall rhabdomyoma (arrow).

Figure 18

Fibroma: 63-year-old incidentally found to have LV mass when she presented with atrial fibrillation. (a) Mid-esophageal 4-chamber view with large anterolateral wall intramyocardial mass (arrow) (b) Mass as seen well in the transgastric long axis view inferior-lateral (posterior) wall. (c) Surgeons view from an incision made in the apex of the left ventricle. (d) A golf ball-sized tumor was noted in the posterolateral wall of the left ventricle. The tumor was completely excised without entering the left ventricular cavity, 3.7 × 3.2 × 2.8 cm firm white solid mass diagnosed as a fibroma. (e) 4-ch Fiesta sequence showing 3.7 cm mass in the anterolateral wall. (f) There is intense late gadolinium enhancement of the mass. Abbreviation: LV, left ventricle.

Figure 19

74-year-old woman with history of breast cancer TEE 2D bicaval view right atrial (RA) superior vena cava (SVC) junction cardiac lipoma on echo. (a) Shows a 1.8 × 1.5 cm homogeneous, well circumscribed rounded mass, in a posterior-superior position within the RA, arising from the mouth of the SVC as it enters the right atrium. (b) Subtle color Doppler velocity acceleration suggesting mild obstruction to the SVC by the RA. Abbreviations: 2D, 2-dimensional; TEE, transesophageal echocardiography.

Figure 20

74-year-old woman with history of breastcancermass was differentiated as a lipoma by CMR. (a) T1-weighted image (fat is bright). (b) Is a T1 fat suppression series where fat gets dark. (c) T1-weighted spoiled gradient echo pulse LAVA—water only. (d) T1-weighted spoiled gradient echo pulse liver acquistion with volume acquisition)—fat only. Abbreviation: CMR, cardiac magnetic resonance.

Figure 21

64-year-old woman with mental status changes TTE and MRI in a patient with lipomatous hypertrophy of atrial septum (LHAS). (a) Apical 4-chamber view left ventricle (LV), left atrium (LA) showing massive LHAS particularly notable in the superior limbus. (b) In the 2 chambers view, the LHAS shows extensive mass. (c) In the subcostal view, the clearing of the fossa ovalis (FO) sometimes referred to as the ‘dumbbell’ atrial septal configuration and makes a strong case for the LHAS. (d) Cardiac MRI confirmed echo suspicion of massive LHAS sparing the fossa ovalis in T1-weighted spoiled gradient echo pulse LAVA—water only sequence. Abbreviations: MRI, magnetic resonance imaging; TTE, transthoracic echocardiography.

Figure 22

Calcified amorphous tumor 3 different examples of imaging modalities. (a) Upper panel shows a normal mitral annulus and lower panel shows a calcified amorphous tumor (CAT) with the caseous liquefaction material just under the valve leaflets (arrow). (b) TTE upper panel shows CAT (arrow), lower panel showing increased gradient across the mitral inflow mean gradient of nearly 4 mmHg. (c) Upper panel shows the CAT on a cardiac CT scan without IV contrast and lower panel shows the CAT with IV contrast. (d) CAT as visualized on a chest x-ray upper panel frontal view, lower panel lateral view with arrows pointing out the calcium in the MV annulus. Abbreviations: CT, computed tomography; IV, intravenous; MV, mitral valve; TTE, transthoracic echocardiography.

Figure 23

Pericardial cyst in a 54-year-old woman with chest positional chest tightness and dyspnea. (a) Subcostal view showing an echolucent space adjacent to the right cardiac border (arrow). (b) Gross pathology right cardiophrenic pericardial cyst, 6.6 × 5.7 × 2.5 cm, uninoculated and serous fluid filled the benign mass.

Figure 24

Angiosarcoma (AS) in a 60-year-old woman that presented with tamponade, and a right atrial (RA) mass. (a) TTE of RA with 2.8 × 1.8 cm mass in the dome and around the wall atrial chamber. (b) CMR heterogenous, nonobstructive right atrial mass which extends along the posterior and posterolateral wall and fills the right atrial appendage. Top right most image shows mild perfusion and bottom right shows moderate patchy late gadolinium enhancement. The location along with these features suggests angiosarcoma as the diagnosis. (c) Surgical view of the tumor upon opening of the RA. (d) Gross pathology of the surgical specimen with rim of the RA. Abbreviations: CMR, cardiac magnetic resonance; TTE, transthoracic echocardiography.

Figure 25

The location of the mass is highly informative on echo as to first understanding of the type of cardiac mass. Abbreviations: LHAS, lipomatous hypertrophy of the atrial septum; NBTE, nonbacterial thrombotic endocarditis; UHGPS, undifferentiated high-grade pleomorphic sarcoma.