Blank DISCLOSURES INTRACARDIAC MASSES MULTI-MODALITY IMAGING ECHO HAWAII JANUARY 2017 NONE

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1 Blank INTRACARDIAC MASSES MULTI-MODALITY IMAGING ECHO HAWAII JANUARY 2017 David A. Orsinelli, MD, FACC, FASE Director, Structural Heart Imaging Professor, Internal Medicine The Ohio State University Division of Cardiovascular Medicine Columbus, Ohio 1 DISCLOSURES NONE 2

ARTIFACTS REVERBERATIONS REFRACTION SIDE LOBE NEAR FIELD CLUTTER INTRACARDIAC MASSES NORMAL VARIANTS / NON- PATHOLOGIC FINDINGS PATHOLOGIC FINDINGS THROMBI TUMORS

TERMINALIS o LIPOMATOUS HYPERTROPHY o PECTINATE MUSCLES o SUTURE LINES LA o POST TXP SUTURE LINE o LIGAMENT OF MARSHALL o MAC o CORONARY SINUS o LIPOMATOUS

2 ARTIFACTS REVERBERATIONS REFRACTION SIDE LOBE NEAR FIELD CLUTTER INTRACARDIAC MASSES NORMAL VARIANTS / NON- PATHOLOGIC FINDINGS PATHOLOGIC FINDINGS THROMBI TUMORS BENIGN MALIGNANT PRIMARY METASTATIC 3 LOCATION OF COMMON (NON-PATHOLOGIC) MASSES RA o DEVICE LEADS o CATHETERS o EUSTACHIAN VALVE o CHIARI NETWORK o CRISTA TERMINALIS o LIPOMATOUS HYPERTROPHY o PECTINATE MUSCLES o SUTURE LINES LA o POST TXP SUTURE LINE o LIGAMENT OF MARSHALL o MAC o CORONARY SINUS o LIPOMATOUS HYPERTROPHY o PECTINATE MUSCLES RV o MODERATOR BAND o TRABECULATIONS o PAPILLARY MUSCLES o DEVICE LEADS LV o FALSE TENDONS o REDUNDANT CHORDAE o TRABECULATIONS o PAPILLARY MUSCLES

RA MASS IN A CANCER PATIENT 48 Y/O MAN WITH A HISTORY OF A

MOS PTA PRIOR DVT / PE ON ENOXAPARIN (MISSED 5 DOSES) PRESENTED

MALIGNANCY NO CVC (REMOVED 5 MOS PTA) TTE REQUESTED TO ASSESS RA

TV 5 RA MASS IN A CANCER PATIENT CT / MRI IMAGES TTE POST CHEMO /

ON RA FREE WALL AND SECOND MASS ON ANT TV LEAFLET: Isointense on

No fat component, no perfusion with firstpass perfusion imaging.

3 RA MASS IN A CANCER PATIENT 48 Y/O MAN WITH A HISTORY OF A PANCREATIC NEUROENDOCRINE TUMOR, S/P PARTIAL PANCREATECTOMY 18 MOS PTA PRIOR DVT / PE ON ENOXAPARIN (MISSED 5 DOSES) PRESENTED WITH CP / DYSPNEA CTPE NEGATIVE, RA MASS CONCERNING FOR MALIGNANCY NO CVC (REMOVED 5 MOS PTA) TTE REQUESTED TO ASSESS RA MASS LARGE SESSILE MASS ON RA FREE WALL MOBILE MASS ATTACHED TO TV 5 RA MASS IN A CANCER PATIENT CT / MRI IMAGES TTE POST CHEMO / CVC REMOVAL (5 mos PTA) CT PE IMAGES WITH 2 RA MASSES MRI: MASS ON RA FREE WALL AND SECOND MASS ON ANT TV LEAFLET: Isointense on T1 and T2 weighted imaging. No fat component, no perfusion with firstpass perfusion imaging. Masses remain hypointense at long inversion times and on late gadolinium enhancement imaging. Most consistent with thrombus. 6

ADVANTAGES / LIMITATIONS ECHOCARDIOGRAPHY ADVANTAGES Widely Available Portable Versatile Hemodynamics / valves Usually 1 st line test

4 ROLE OF ECHO IN EVALUATING CARDIAC MASSES USUALLY THE INITIAL DIAGNOSTIC MODALITY IN THE DETECTION OF INTRACARDIAC MASSES CLINICAL APPLICATION OF ECHO GUIDELINE (2003) AND THE AUC (2011) DOCUMENTS SUPPORT THIS ROLE 7 INTRACARDIAC MASSES ECHO vs MRI EACH MODALITY HAS ADVANTAGES / LIMITATIONS ECHOCARDIOGRAPHY ADVANTAGES Widely Available Portable Versatile Hemodynamics / valves Usually 1 st line test DISADVANTAGES Image Quality / Body Habitus No Tissue Characterization Limited Extracardiac Information Less Sensitive (e.g. apical thrombi) 8

5 INTRACARDIAC MASSES ECHO vs MRI EACH MODALITY HAS ADVANTAGES / LIMITATIONS CARDIAC MRI ADVANTAGES Image Quality Perfusion Tissue Characterization More Sensitive (e.g. apical thrombi) Wide Field of View (extracardiac information) DISADVANTAGES Cost Not Portable Less Availability Less Experience 9 Cardiac Lipoma on MRI Raman et al, Circ 07

6 GREAT CLOTS INTRACARDIAC THROMBI ARE THE MOST COMMONLY ENCOUNTERED INTRA-CARDIAC MASSES 11 AN INTERESTING LV THROMBUS 59 Y/O MAN PRESENTED WITH AN ACUTE NSTEMI CARDIAC CATH: HIGH GRADE LAD LESIONS (DES x 2) AND TOTAL DISTAL LAD OCCLUSION(+/- POBA) ECHO 24 HOURS LATER 12

7 AN INTERESTING LV THROMBUS 13 AN INTERESTING LV THROMBUS D/C ON WARFARIN, BB AND ACEi ECHO 3 MONTHS LATER 14

AN INTERESTING LV THROMBUS WARFARIN STOPPED, REPEAT ECHO 1 MONTH LATER

WARFARIN INDEFINITELY 15 CARDIAC TUMORS PRIMARY BENIGN MYXOMA LIPOMA

MALIGNANT SARCOMA ANGIOSARCOMA RHABDOMYOSARCOMA FIBROSARCOMA LEIOMYOSARCOMA

8 AN INTERESTING LV THROMBUS WARFARIN STOPPED, REPEAT ECHO 1 MONTH LATER WARFARIN RESUMED, REPEAT ECHO 6 WEEKS LATER DEMONSTRATED NO THROMBUS, ON WARFARIN INDEFINITELY 15 CARDIAC TUMORS PRIMARY BENIGN MYXOMA LIPOMA PERICARDIAL CYST FIBROELASTOMA RHADBOMYOMA* TERATOMA* FIBROMA* PRIMARY MALIGNANT SARCOMA ANGIOSARCOMA RHABDOMYOSARCOMA FIBROSARCOMA LEIOMYOSARCOMA LYMPHOMA 16 *Mostly Pediatric METASTATIC LUNG BREAST RENAL CELL MELANOMA LYMPHOMA / LEUKEMIA ADENOCARCINOMA GI

LOCATION OF PATHOLOGIC MASSES / TUMORS RA o THROMBUS o TUMORS o MYXOMA o ANGIOSARCOMA o RENAL CELL LA o THROMBUS o TUMORS o MYXOMA o LIPOMA (SEPTAL) o LEIOMYOSARCOMA o METASTATIC (via PV) RV o

9 LOCATION OF PATHOLOGIC MASSES / TUMORS RA o THROMBUS o TUMORS o MYXOMA o ANGIOSARCOMA o RENAL CELL LA o THROMBUS o TUMORS o MYXOMA o LIPOMA (SEPTAL) o LEIOMYOSARCOMA o METASTATIC (via PV) RV o THROMBUS o TUMORS o RHADOMYOMA o ANGIOSARCOMA o METASTATIC LV o THROMBUS o TUMORS o RHABDOMYOMA o FIBROMA o SARCOMA o METASTATIC PERICARDIUM o TERATOMA o MALIGNANT EFFUSIONS (1º or METASTATIC) PRIMARY CARDIAC TUMORS Feigebaum 7 th ed 2010, pg 713 BENIGN (OUTNUMBER MALIGNANT 3:1) MYXOMA MOST COMMON BENIGN TUMOR (30%)?? PFE RHABDOMYOMA, FIBROMA, HEMANGIOMA, TERATOMA MALIGNANT ANGIOSARCOMA, RHABDOMYOSARCOMA, FIBROSARCOMA, MESOTHELIOMA, LYMPHOMA, LEIOMYOSARCOMA 18

BENIGN vs MALIGNANT: ECHO CHARACTERISTICS BENIGN (e.g.

Angiosarcoma) INFILTRATE / CROSS TISSUE PLANES INVADE / OBLITERATE CONTIGUOUS STRUCTURES

CARDIAC MALIGNANCIES Direct Invasion (e.g. Lung, Esophageal) From venous system (e.g. Lung, Renal cell) Hematogenous / Lymphatic Spread (e.

LEUKEMIAS OFTEN INVOLVE THE HEART (PERICARDIUM) BREAST / LUNG ACCOUNT FOR MOST METASTATIC

10 BENIGN vs MALIGNANT: ECHO CHARACTERISTICS BENIGN (e.g. Myxoma) WELL - CIRCUMSCRIBED MAY ENHANCE WITH CONTRAST (DEPENDS ON VASCULARITY) MALIGNANT (e.g. Angiosarcoma) INFILTRATE / CROSS TISSUE PLANES INVADE / OBLITERATE CONTIGUOUS STRUCTURES EFFUSIONS MAY ENHANCE WITH CONTRAST 19 METASTATIC CARDIAC TUMORS MUCH MORE COMMON THAN PRIMARY CARDIAC MALIGNANCIES Direct Invasion (e.g. Lung, Esophageal) From venous system (e.g. Lung, Renal cell) Hematogenous / Lymphatic Spread (e.g. Breast, Lymphoma) MELANOMA ~50% HAVE CARDIAC INVOLVEMENT (PERICARDIUM AND INTRACARDIAC) LEUKEMIAS OFTEN INVOLVE THE HEART (PERICARDIUM) BREAST / LUNG ACCOUNT FOR MOST METASTATIC CARDIAC TUMORS (MORE COMMON THAN OTHER TUMORS) PERICARDIUM OFTEN SITE OF METASTASIS MALIGNANT EFFUSIONS 20

11 CASE 1 59 Y/O WOMAN PRESENTS TO PCP WITH DOE AND EDEMA TTE OBTAINED NORMAL OTHER THAN A MITRAL VALVE MASS REFERRED TO CARDIO FOR EVALUATION OF THE MASS NO HX OF CVA / TIA, CP, INFECTIOUS SX 21 CASE 1 ECHO 22

2003: 146:404 Case 2 37 y/o female presents with 1hr hx of chest discomfort Obese,

12 CASE 1 DIFFERENTIAL DIAGNOSIS OLD HEALED VEGETATION METASTATIC TUMOR ARTIFACT PRIMARY CARDIAC TUMOR MYXOMA PAPILLARY FIBROELASTOMA 23 Gowda Am H J.2003: 146:404 Case 2 37 y/o female presents with 1hr hx of chest discomfort Obese, BP 150/90, normal cardiac exam Initial Tn normal? AMI vs Pericarditis STAT ECHO Case compliments of T. Ryan

14 CASE 2 MANAGEMENT: WHAT IS THE NEXT STEP? TEE FOR CSE NEGATIVE EXCEPT FOR AV MASS CONSISTENT WITH A PFE SURGICAL RESECTION OF MASS, PATH CONFIRMED A PFE 27

MANAGEMENT OF PFE SYMPTOMATIC PATIENTS SURGICAL EXCISION MANAGEMENT OF INCIDENTAL FIBROELASTOMA SOMEWHAT CONTROVERSIAL SOME ADVOCATE SURGICAL EXCISION (esp if > 1 cm, mobile, left sided) OTHERS

15 MANAGEMENT OF PFE SYMPTOMATIC PATIENTS SURGICAL EXCISION MANAGEMENT OF INCIDENTAL FIBROELASTOMA SOMEWHAT CONTROVERSIAL SOME ADVOCATE SURGICAL EXCISION (esp if > 1 cm, mobile, left sided) OTHERS ADVOCATE WATCHFUL WAITING + ANTIPLATELET THERAPY 29 Bruce. The Practice of Clinical Echocardiography Jan 1, 2012 LMS CASE A 52 WOMAN WITH A HISTORY OF A HYSTERECTOMY FOR UTERINE LEIOMYOSARCOMA PRESENTS FOR F/U ASYMPTOMATIC, FELT TO BE IN REMISSION TTE ORDERED FOR F/U OF CHEMO 30

16 LMS INITIAL ECHO 31 LMS 2 MONTHS LATER SHE DEVELOPED PROGRESSIVE DOE AND LE EDEMA, ECHO REPEATED 32

17 CMR ORDERED TO ASSESS TUMOR vs THROMBUS Y/O WOMAN PRESENTED WITH FATIGUE, MALAISE, DOE AND LE EDEMA TTE OBTAINED AT OSH LARGE RA MASS 9 mm HG GRADIENT ACROSS THE TV SMALL TO MODERATE PERICARDIAL EFFUSION TEE PERFORMED AT OUR HOSPITAL A LARGE RA MASS 34

18 A LARGE RA MASS CARDIAC MRI CARDIAC SURGERY: MASS REMOVED, PATH CONSISTENT WITH MYXOMA FULL RECOVERY, ASSX, F/U ECHOS WITH NO RECURRENCE MYXOMA MOST COMMON BENIGN CARDIAC TUMOR LOCATION 75 % LA 15 % RA 5 % LV 5 % RV MOST ARE ISOLATED CARNEY COMPLEX Multiple tumors (atrial and extracardiac myxoma, schwannomas, endocrine tumors) and pigmentation abnormalities A LARGE RA MASS

19 ANGIOSARCOMA 43 y/o MAN PRESENTED WITH FATIGUE, MALAISE, WEIGHT LOSS AND DYSPNEA. 37 MRI DEMONSTATRATED COMPLEX MASS THAT IS PERFUSED Bx C/W ANGIOSARCOMA TREATMENT OPTIONS LIMITED MEDIAN SURVIVAL 6-12 MONTHS ANGIOSARCOMA 38

20 LYMPHOMA 38 Y/O MAN WITH PRESENTED WITH DYSPNEA, EDEMA AND WEIGHT LOSS AND DIFFUSE ADENOPATHY LN BIOPSY CONSISTENT WITH B-CELL LYMPHOMA (STAGE 4B) STAGING PET-CT: HYPERMETABOLIC INTRACARDIAC MASS WITH PERICARDIAL INVOLVEMENT ECHO TO ASSESS MASS AND PERICARDIUM AS WELL AS EF PRE CHEMO 39 LYMPHOMA TTE CONFIRMS MASS AND SMALL EFFUSION 40

21 LYMPHOMA F/U POST CHEMO 41 RX WITH 6 CYCLES OF R-CHOP SERIAL ECHOS / CT SCANS REVEAL DECREASE IN SIZE OF MASSES REPEAT TTE 7 MONTHS LATER WITH NO MASS/EFFUSION/NL EF F/U CT SCANS NEGATIVE DISEASE FREE AT 8 YEARS A NEW SOMALIAN IMMIGRANT WITH CHF 42

22 A NEW SOMALIAN IMMIGRANT WITH CHF 43 A 77 Y/O WOMAN WITH ADULT ONSET ASTHMA, MULTIPLE STROKES AND CHF 44

HYPEREOSINOPHILIC SYNDROME (HES) EOSINOPHILIC INFILTRATION / MEDIATOR RELEASE CAUSE END- ORGAN DAMAGE CARDIAC INVOLVEMENT DUE TO MYOCARDIAL INFILTRATION / TOXICITY / INTRACAVITARY THROMBUS EMF:

23 HYPEREOSINOPHILIC SYNDROME (HES) EOSINOPHILIC INFILTRATION / MEDIATOR RELEASE CAUSE END- ORGAN DAMAGE CARDIAC INVOLVEMENT DUE TO MYOCARDIAL INFILTRATION / TOXICITY / INTRACAVITARY THROMBUS EMF: Restrictive filling, tethering of MV / TV PRIMARY (NEOPLASTIC) SECONDARY (REACTIVE) INFECTION (PARASITES) SOLID TUMORS T-CELL LYMPHOMA IDIOPATHIC SYNDROMIC (e.g. Churg-Strauss) CHURG-STRAUSS (EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS: EGPA) SINUSITIS, ASTHMA, VASCULITIS,UPPER AIRWAY, EAR,SKIN, NEUROPATHY, CNS VASCULITIS, RENAL, GI, MSK CARDIAC DISEASE CAUSE OF ~50% OF DEATHS 45 DON T FORGET THE PULMONARY VEINS 63 Y/O MALE SMOKER WITH A LARGE RIGHT LUNG MASS BX REVEALED SQUAMOUS CELL CA DEVLOPED ACUTE LE NUMBNESS, LOW BACK AND HIP PAIN. SURGERY REVEALED A SADDLE EMBOLUS AT THE AORTIC BIFURCATION PATH CONSISTENT WITH CARCINOMA TTE NEGATIVE, TEE PERFORMED TEE FROM A SECOND PATIENT WITH A HISTORY OF OSTOSARCOMA METASTATIC TO THE RIGHT LUNG WHO PRESENTED WITH A CVA 46 JASE 1995;8:97

NOT SO MUCH FOR THE PATIENT THROMBI ARE NOT UNCOMMON TUMORS ARE RELATIVELY RARE BUT CLINICALLY IMPORTANT CLINICAL SCENARIO MAY HELP

24 DON T FORGET THE PULMONARY VEINS A 63 Y/O MAN UNDERWENT BILATERAL LUNG TRANSPLANTS 11 DAYS POST OP HE SUFFERED A CVA MRI WITH MULTIPLE EMBOLIC INFARCTS TTE UNREMARKABLE TEE PERFORMED 47 INTRACARDIAC MASSES SUMMARY FINDING INTRACARDIAC MASSES IS EXCITING (FOR THE READER), NOT SO MUCH FOR THE PATIENT THROMBI ARE NOT UNCOMMON TUMORS ARE RELATIVELY RARE BUT CLINICALLY IMPORTANT CLINICAL SCENARIO MAY HELP DIFFERENTIATE EXTENSIVE DIFFERENTIAL OF PRIMARY TUMORS (75% ARE BENIGN) ECHO, CT AND MRI ALL PLAY A ROLE EACH HAS ADVANTAGES / LIMITATIONS 48

25 Acknowledgments: THANK YOU T. Ryan and K. Zareba for providing several cases 49

Cardiac Mass and Mass-like Structures

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