ECHO SYMPOSIUM. August 16, 2012 UP Techno Hub

ECHO SYMPOSIUM August 16, 2012 UP Techno Hub

OBJECTIVES 1. To present a case of right atrial mass 2. To discuss the epidemiology, clinical presentation, approach to diagnosis, treatment and prognosis of right atrial mass. 3. To discuss the role of 2 D echocardiography in space occupying lesion of the heart.

SYNOPSIS OF THE CASE 68/M, diagnosed HCC (2010), no history of chemo nor radiotherapy Hypertensive controlled Perindopril 5 mg/tab OD Amlodipine 5 mg/tab OD Previous smoker Denies chest pain, easy fatigability, difficulty of breathing or shortness of breath Good functional capacity Referred for CP evaluation prior to TACE

SYNOPSIS OF THE CASE Physical Examination BP 120/80 mm Hg both upper extremities CR 65 bpm No neck vein distention, clear breath sounds Adynamic precordium, apex beat at 5 th ICS left MCL, no heaves nor thrills, split S1, fixed S2, grade 3/6 rumbling diastolic murmur, heard best at the apex, non radiating, no S3 nor S4 (+) ascites & hepatosplenomegaly Full and equal pulses, no edema

SYNOPSIS OF THE CASE Hgb 11 g/dl Hct 0.33 WBC ct 7.4 Seg 45 Lymph 40 Mono 11 Eos 3 Baso 1 Plt Ct 408 Hgb A1c 4.7% TP 71 g/l Alb 30 g/l Glob 41 g/l A/G 0.70 BUN 4.3 mmol/l Crea 73.6 umol/l Na 141.2 mmol/l K 3.53 mmol/l SGOT 111 U/L SGPT 60 U/L ALP 550 U/L

SYNOPSIS OF THE CASE PT 67% INR 1.13 HbsAg Anti-HBS Anti-HBc HBeAg Anti-HBe Anti-HAV Anti-HCV Alpha Feto Protein Non-Reactive Non-Reactive Non-Reactive Non-Reactive Non-Reactive Non-Reactive Non-Reactive 1199.26 ng/ml

SYNOPSIS OF THE CASE Elevated liver enzymes Elevated alpha feto protein Hypoalbuminemia Deranged protime Abdominal MRI: Multifocal hepatocellular carcinoma No hepatic vein invasion

ECG

PLAX 2 D Echo with Doppler

SAX 2 D Echo with Doppler

4C 2 D Echo with Doppler

3C 2 D Echo with Doppler

ASSESSMENT Right Atrial Mass T/C Myxoma, Hypertensive Heart Disease Not in Failure, HCC Clinically High risk Embolization Valve obstruction Procedural Low risk Recommendation Urgent Open Heart Surgery

Guidelines for the use of Echocardiography Adapted from Cheitlin MD, ACC/AHA Guidelines for the Clinical Application of Echocardiography, 1997

NORMAL VARIANTS Ragland M, The Role of Echocardiography in Diagnosing Space-Occupying Lesions of the Heart, Clinical Med & Research, Vol 4, No 1: 22-32

NORMAL VARIANTS Ragland M, The Role of Echocardiography in Diagnosing Space-Occupying Lesions of the Heart, Clinical Med & Research, Vol 4, No 1: 22-32

Distinguishing Intra-Cardiac Masses Characteristic Thrombus Tumor Vegetation Location LA (esp. if enlarged or MV disease) LA (myxoma) Myocardium Pericardium Valves Usually valvular Occasionally on ventricular wall or Chiari network LV ( EF or segmental WMA) Appearance Usually discrete and somewhat spherical or laminated against LV apex or LA wall Various: may be circumscribed or irregular Irregular shape, attached to proximal side (upstream) of the valve with motion independent from the valve Associated findings Underlying etiology usually evident Intracardiac obstruction depending on site of tumor Valvular regurgitation usually present LV systolic dysfxn or segmental WMA Fever, systemic signs of endocarditis, positive blood cultures MV disease with LAE

Distinguishing Intra-Cardiac Masses Adapted from Armstrong WF, Feigenbaum s Echocardiography 7 th Edition

Distinguishing Intra-Cardiac Masses Adapted from Armstrong WF, Feigenbaum s Echocardiography 7 th Edition

Distinguishing Intra-Cardiac Masses Adapted from Armstrong WF, Feigenbaum s Echocardiography 7 th Edition

Distinguishing Intra-Cardiac Masses Adapted from Armstrong WF, Feigenbaum s Echocardiography 7 th Edition

INTRODUCTION Primary tumors are rare. 0.0017 % to 0.19% post mortem. 75% - benign 40% are myxomas Most tend to be asymptomatic and have no specific symptoms or signs. Aoyagi S, Right Atrial Myxoma in a Patient Presenting with Syncope Kurume Medical Journal Vol 51, No 1, 2004

Primary Cardiac Tumors Ragland M, The Role of Echocardiography in Diagnosing Space-Occupying Lesions of the Heart, Clinical Med & Research, Vol 4, No 1: 22-32

MYXOMA 20% RA 5% Multicentric 75% Most arise from the interatrial septum at the border of fossa ovalis LA Ragland M, The Role of Echocardiography in Diagnosing Space-Occupying Lesions of the Heart, Clinical Med & Research, Vol 4, No 1: 22-32

Intracardiac Masses Oliveira R, Cardiac Myxoma: A 13-Year Experience in Echocardiographic Diagnosis Rev Port Cardiol 2010; 29 (07): 1087-1100

SIGNS & SYMPTOMS Obstruction of intracardiac blood flow Interference with valve function Arrythmias Pericardial effusions Embolization Systemic or constitutional symptoms Salm T, Unusual Primary Tumors of the Heart, Seminars in TCVS, Vol 12, No 2 (April), 2000: pp 89-100

SIGNS & SYMPTOMS The clinical feature of masses are determined by their location, size and mobility. TRIAD: Embolization Intracardiac Obstruction Constitutional Signs and Symptoms Ragland M, The Role of Echocardiography in Diagnosing Space-Occupying Lesions of the Heart, Clinical Med & Research, Vol 4, No 1: 22-32

Clinical Features Oliveira R, Cardiac Myxoma: A 13-Year Experience in Echocardiographic Diagnosis Rev Port Cardiol 2010; 29 (07): 1087-1100

Chest X-ray Grebenc ML, Cardiac Myxoma: Imaging Features, AFIP Archives, 2002

Echo Characteristics of Masses Prone to Embolization Small Irregular shape Mobile surface Prolapsing tumor Polypoid Demir M, Atrial Myxoma: An Unusual Cause of MI, THIJ 2005;32:445-7

Right Atrial Myxoma Uncommon Accounts for only 20% of all myxomas Usually arises from the inter-atrial septum Polypoid Pedunculated Patrianakos A, Right Atrial Myxoma: Echocardiograhic Apperance Euro Jour of Echo 2008 9, 422-423

51/M Progressive dyspnea on exertion TTE: large RA mass prolapsing through the tricuspid valve into the right ventricle Case Reports Discharged AMA Died about one hour after getting home while trying to stand up from the sitting position. Ojji D, A probable right atrial myxoma prolapsing through the tricuspid valve into the Righr ventricle: a case report, Cases Journal 2008, 1:386

62/F Syncope TTE: large right atrial mass prolapsing through the tricuspid valve into the right ventricle Underwent open heart surgery with excision of myxoma Case Reports Aoyagi S, Right Atrial Myxoma in a Patient Presenting with Syncope Kurume Medical Journal Vol 51, No 1, 2004

Right Atrial Myxoma The atrial mass was found to prolapse through the tricuspid valve into the right ventricle. Complete obstruction of the tricuspid valve which resulted can result to syncope and sudden death. Commonest cause of death in right atrial myxoma especially when it extends to the tricuspid valve. Patrianakos A, Right Atrial Myxoma: Echocardiograhic Apperance Euro Jour of Echo 2008 9, 422-423

Role of Echocardiography Can provide both anatomic and physiologic information about the mass. Availability Real time images Noninvasive Relatively inexpensive Serial studies Ragland M, The Role of Echocardiography in Diagnosing Space-Occupying Lesions of the Heart, Clinical Med & Research, Vol 4, No 1: 22-32

Role of Echocardiography The use of 2 D echocardiography was useful for determining the sites of the tumor stalks and for the choice of surgical treatment. Watanabe K, Usefulness of 2-D Echocardiography for Diagnosis of the Sites Of Origin in Myxoma, TJM, 1983, 139, 327-328

M-Mode of RA Myxoma Pechacek LW, The Echocardiographic Spectrum of Atrial Myxoma: A Ten-Year Experience, THIJ Vol 13, No. 2, June 1986

BENIGN vs MALIGNANT Benign Common Asymptomatic Heterogenous Minimal Calcifications Attached to IAS Mobile Malignant Rare Symptomatic Homogenous (+) Calcifications Invasive Fixed

Manifest in the heart: mass, pericardial disease or myocardial involvement METASTATIC Tumor spread to heart: direct invasion, hematogenous spread

METASTATIC Percell R, Atrial Myxoma: Case Report and a Review of the Literature, Heart Disease Vol 5 No 3, May/June 2003

METASTATIC

Surgery Speedy growth of the tumor Risk for embolization Blocking the valve orifice Butany J, Cardiac Tumors: Diagnosis and Management Lancet Oncol 2005; 6219-28

TREATMENT Treatment is surgical with en bloc resection including rim of septum around base. Recurrence in about 1-5% of cases (incomplete resection, implantation from first tumor etc) - therefore annual surveillance recommended. Butany J, Cardiac Tumors: Diagnosis and Management Lancet Oncol 2005; 6219-28

TREATMENT Patients with cardiac metastases can undergo palliative debulking. Radiotherapy } Chemotherapy Very few data Butany J, Cardiac Tumors: Diagnosis and Management Lancet Oncol 2005; 6219-28

In our patient... 68/M with HCC Incidental finding of isolated sporadic right atrial mass (Myxoma) Open heart surgery (atrial mass excision) GI and Oncology referral

Key Points Primary Cardiac tumors are rare and usually benign. Clinical presentation based on location and size of mass. Echo (TTE and TEE) remains the initial and reliable imaging test. Treatment usually involves surgery for tumors.

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