connie tsao non invasive conference april 7 2010 n.
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  1. Connie Tsao Non-invasive Conference April 7, 2010 Cardiac Masses

  2. Outline • Non-tumors • Normal Variants • Catheters • Thrombotic disease • Infective endocarditis • Cardiac tumors • Epidemiology • Clinical Manifestations • Primary Cardiac Tumors • Benign • Malignant • Metastatic Tumors

  3. Non-tumors

  4. Normal Variants • Structural variants • False tendon: fibrous/fibromuscular • Eustachian valve • Chiari network • Prosthetic material • Catheters • Pacing wires • Cardiac assist devices

  5. Arrhythmogenic potential? • Series of 15 patients with idiopathic LV tachycardia vs. controls referred for echo • All ILVT had false tendon from IL wall-septum • 2/3 of these >2 mm • 34/671 (5%) of controls had false tendon • Oriented across LV • <2 mm Thakur RK, Circ 1996

  6. Epidemiology • In FHS Original and Offspring cohort: 101 participants with LV false tendons (2% of population) Kenchaiah S et al, JASE 2009

  7. Associated with: • Lower BMI • Innocent murmur • ECG-LVH • Not associated with ventricular ectopy, or other ECG abnormalities • No excess mortality in 7.7±1.6 yrs follow-up Kenchaiah S et al, JASE 2009

  8. Eustachian valve

  9. Persistent Eustachian valve • Case reports of association between Eustachian valve and PFO • In 306 pts referred for TEE (211 for cryptogenic CVA): • 143/211 (68%) of cryptogenic stroke group had EV • 31/95 (33%) of controls had EV • 70% of pts with EV had PFO • ? Effect of flow on increasing patency of PFO Strotmann JM, Heart 2001 Schuchlenz HW, JASE 2004

  10. Chiari Network • Hans Chiari, 1897: 11 pts, fibrous network in RA • Remnant of right valve of sinus venosus • Directed IVC flow through fossa ovalis to LA • Incomplete resorption • 1-4% in autopsy studies

  11. Chiari network and PFO • 1436 pts consecutive pts referred for TEE • Prevalence 29/1436 (2%) • Chiari network present in: • 24/522 (4.6%) referred for paradoxical embolus • 5/913 (0.5%) controls • PFO present in: • 24/29 (83%) with Chiari • 44/160 (28%) controls • Significant R-L shunt by agitated saline in 1/3 with Chiari Schneider B, et al, JACC 1995

  12. Prosthetic Material

  13. Impella

  14. Intracardiac Thrombi • Accounts for 15-20% strokes • Major source: LA thrombi (>45% cases) • LA thrombi detected by TEE: • Acute AF: 14% • Chronic AF: 27% • AF with clinical thromboembolism: 43% • Other: Aorta, valve prostheses, inter-atrial septum aneurysm • LV thrombi • Post-MI • Significant LV dysfunction • Stoddard MF et al, JACC 1995; Manning WJ et al, Ann Int Med 1995

  15. LAA masses

  16. LV Thrombus

  17. Same patient, LGE

  18. LV Thrombus: Value of LGE-CMR • 784 consecutive pts with LVEF <50% • Thrombus detection: • 37 (4.7%) by cine-CMR • 55 (7%) by LGE-CMR • Pathologic correlation in 8 pts, LV thrombus in 5 • All 5 detected by LGE-CMR • 2 detected by cine-CMR • Cine CMR missed small intracavity and mural thrombi Weinsaft JW et al, JACC 2008

  19. Weinsaft JW et al, JACC 2008

  20. LV Thrombus: Contrast Echo vs CMR • 121 pts post MI or clinical heart failure TTE, contrast-TTE, LGE-CMR • LV thrombus in 24 pts by LGE-CMR • Larger infarcts, aneurysm, lower LVEF • TTE sensitivity 33%, Contrast TTE: 61% • Low LVEF predictor of thrombus detection by CMR • Thrombi detected by DE-CMR vs contrast echo: mural, small apical • Close agreement with contrast echo (k=0.79) Weinsaft JW et al, JACC Imaging 2009

  21. Asymptomatic 50 year old man SSFP First pass perfusion Hoey ED et al, Clin Radiol 2009

  22. Cardiac Tumors

  23. Primary cardiac tumors • Majority (>75%) are benign • Rare; incidence of <0.001-0.03% in autopsy studies

  24. Primary Benign Tumors

  25. Braunwald’s Heart Disease, 7th Ed.

  26. Classic Triad of Symptoms • Intracardiac obstruction: • Dyspnea, orthopnea, pulmonary edema • Presyncope/syncope • Angina, claudication • Systemic embolization: • CVA, retinal artery emboli • Emboli to extremities • Constitutional symptoms: fever, fatigue, weight loss, arthalgia

  27. Myxoma • Mean age 50 years at diagnosis • F>M (60-70%) • 80% in left atrium, 15% in right atrium • Can occur in ventricles • 90% solitary, 7% Carney complex • Average size 5-6 cm • Attachment to fossa ovalis

  28. Pedunculated, gelatinous • Friable/villous surface (1/3) emboli • Histology: • Mesenchymal cells in mucopolysaccharide stroma • Production of VEGF angiogenesis

  29. Clinical manifestations • Factors: size, anatomic location • Pulmonary venous or mitral valve obstruction • Stroke/neurologic deficits • Systemic embolization • Constitutional symptoms: fever, weight loss • Anemia, elevated ESR, leukocytosis • ↑IL-6, inflammatory factors

  30. Imaging • Echo • Prolapsing mass across MV/TV • Identification of point of attachment • CMR • Heterogeneous appearance on T1W, T2W images • Patchy LGE • CT • Low attenuation mass, no enhancement • Calcification in 10-15%

  31. T1W post gadolinium

  32. T2W

  33. 58 year old man with dyspnea

  34. Treatment • Resection • Including surrounding septum at attachment • Surgical mortality <5% • Risk for atrial arrhythmias • Recurrence in 2-5% • Recurrence in Carney complex 12-22%

  35. Papillary Fibroelastoma • Incidence 0.002-0.33% in autopsies • Mean age 60 years • Mean size 9 mm (2-70 mm) • 80-90% on valvularendocardium, AV 36%> MV 29%> TV 11% > PV 7% • Downstream side • Histology: fibromyxoid core, rim of elastic fibers covered by endothelial cells • Distinction from Lambl’s excrescence

  36. Clinical manifestations • Embolization: tumor or thrombus • CVA/TIA • PE • Peripheral embolization • MI, angina • Sudden cardiac death • Syncope • 1/3 of patients asymptomatic

  37. Imaging • TTE can miss due to size • CMR not ideal due to high mobility • Well-circumscribed nodule on T1W, T2W • LGE reported • Distinction from vegetation • No significant valvular regurgitation • Location away from valvular free edge

  38. 29 year old woman with incidentally discovered mass… Parthenakis F et al, Cardiovasc Ultrasound 2009