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

6. 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

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

8. 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

9. Eustachian valve

11. 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

12. 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

14. 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

15. Prosthetic Material

16. Impella

17. 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

18. LAA masses

19. LV Thrombus

24. Same patient, LGE

25. 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

26. Weinsaft JW et al, JACC 2008

27. 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

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

29. Cardiac Tumors

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

31. Primary Benign Tumors

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

33. 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

34. 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

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

36. 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

37. 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%

41. T1W post gadolinium

42. T2W

43. 58 year old man with dyspnea

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

45. 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

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

47. 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

48. 29 year old woman with incidentally discovered mass… Parthenakis F et al, Cardiovasc Ultrasound 2009