No abstract
Background Cardiac masses are rare entities and often diagnostically challenging. When incidentally found multimodality diagnostic approach is warranted for further characterization and evaluation of its contribution to the patient’s symptoms. Case report 62-year-old male, smoker, with a history of non-Hodgkin lymphoma treated with radiation and chemotherapy 10 years ago, was admitted due to subacute myocardial infarction. Coronary angiogram showed subacute occlusion of partly collateralized RCA, subsequently treated with dilatation and stenting. Echocardiography revealed signs of dilated cardiomyopathy with severely reduced left ventricular ejection fraction (EF 20%), that could be due to chemotherapy-related cardiotoxicity. On admission CTA was performed to exclude aortic dissection since the patient presented with very severe chest pain radiating to the back. It showed a heterogeneous formation within the right ventricle (RV) extending along the interventricular septum from the apex towards the tricuspid annulus, appearing to involve interventricular septum as well. According to the imaging characteristics the mass was suspected to be a liposarcoma (Figure A). With contrast echocardiography hypoechogenic formation in the RV on parasternal long-axis view could be visualized (Figure B). Due to previous history of malignancy PET scan was performed that revealed hypometabolic RV mass, suggesting a benign tumor, without any sign of metastasis. We decided for percutaneous biopsy that was done under intracardiac echocardiography (ICE) guidance using the view from the RV towards RV outflow tract (Figure C). Histology revealed proliferation of mature adipocytes, either orthotopic or multiplied (Figure D). To exclude well-differentiated liposarcoma FISH (fluorescent in situ hybridization) with amplification of MDM2 gene was undertaken, confirming benign lesion, most probably cardiac lipoma. It was concluded that the mass was an incidental finding, not related to the patient’s symptoms and not causing any functional disturbances; therefore surgical therapy could be avoided. Conclusion While echocardiography remains the first-line imaging modality, multimodality diagnostic approach is mandatory for evaluation and treatment decision of a newly-discovered cardiac mass. Histology provides definitive diagnosis and ICE could be helpful for guiding percutaneous biopsy, thus avoiding invasive open-heart procedures. Figure. Cardiac CTA (A), contrast echocardiography (B), intracardiac echocardiography (C) and histologic specimen (D) of the right ventricular mass (arrows). Abstract P1344 Figure.
Case report: 66-year-old man with a history of mental disorder, presented with acute pulmonary edema and pneumonia. ECG indicated signs of previous anterior wall myocardial infarction. Based on patient history we concluded that it had occured approximately one month before he was admitted. Echocardiography identified mildly dilated left ventricle with moderately reduced ejection fraction with anterior wall akinesia (Figure 1). Apical akinetic segments were filled with thrombus. In accordance with the existing guidelines, we introduced three months of anticoagulation therapy with warfarin. Follow up echocardiography showed large apical pseudo aneurysm (probably in the inferoapical segment) partially filled with thrombus ( Figure 2). With contrast echocardiography (SonoVue) we tried to identify the site of entry into the pseudoaneurysm. However, we could not confirm clear communication. The patient was offered immediate hospital admission for additional MRI diagnosis and operative treatment, but the patient refused all further diagnostic and surgical procedures. The patient is treated with heart failure drugs. Anticoagulation treatment was stopped due to the size of the pseudoaneurysm. Conclusion: Cardiac pseudoaneurysm are rare but clinically significant lesions.1-3 Although often challenging to diagnose, advances in non-invasive imaging (echocardiography, MRI, CT) have improved our ability to distinguish cardiac pseudoaneurysms from other pathologies. Most pseudoaneurysms, particularly if acute or associated with symptoms, require surgical repair or percutaneous exclusion to reduce the risk of rupture and potential for thromboembolism. In patients who have a high risk for surgical (or percutaneous) intervention, particularly when a pseudoaneurysm is chronic in nature, conservative management may be prudent. In our patient, a pseudoaneurysm was detected 6 months after myocardial infarction, which is not usual. We assume that the thrombus in the apex temporary closed the initial rupture of the left ventricle. Introduced anticoagulation therapy may have been an additional factor in the aneurysm development, because it probably contributed to thrombus dissolution.
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