Distinguishing cardiac myxomas from cardiac thrombi by a radiomics signature based on cardiovascular contrast-enhanced computed tomography images.

BACKGROUND: Cardiac myxomas (CMs) and thrombi are associated with high morbidity and mortality. These two conditions need totally different treatments. However, they are difficult to distinguish using naked eye. In clinical, misdiagnoses occur now and then. This study aimed to compare the characteristics of CMs and cardiac thrombi and investigate the value of a radiomics signature in distinguishing CMs from cardiac thrombi, based on cardiovascular contrast-enhanced computed tomography (CECT) images. METHODS: A total of 109 patients who had CMs (n = 59) and cardiac thrombi (n = 50) were enrolled in this retrospective study from 2009 to 2019. First, the lesion characteristics of cardiovascular CECT images were documented and compared by two radiologists. Then all patients were randomly allotted to either a primary group or a validation group according to a 7:3 ratio. Univariate analysis and the least absolute shrinkage and selection operator were used to select robust features. The best radiomics signature was constructed and validated using multivariate logistic regression. An independent clinical model was created for comparison. RESULTS: The best radiomics signature was developed using eight selected radiomics. The classification accuracies of the radiomics signature were 90.8% and 90.9%, and the area under the receiver operating characteristic curves were 0.969 and 0.926 in the training and testing cohorts, respectively. Cardiovascular CECT images showed that the two diseases had significant differences in location, surface, Hydrothorax, pericardial effusion and heart enlargement. The naked eye findings were used to create the clinical model. All metrics of the radiomics signature were higher than those of clinical model. CONCLUSIONS: Compared with clinical model, the radiomics signature based on cardiovascular CECT performed better in differentiating CMs and thrombi, suggesting that it could help improving the diagnostic efficiency.

Complex decision making in a patient with lung cancer with incidentally found fast-growing atrial mass.

Atrial myxomas are typically found in the left atrium and are the most common among overall rare cardiac tumors. Herein, we describe the clinical course of a 72-year-old female with non-small cell lung adenocarcinoma found to have an atrial mass during an imaging for evaluation for lung cancer progression. Differentiating between distinct types of masses can pose a challenge to the treatment team especially in the setting of exiting malignancy. This case demonstrates the complex decision making involved in the diagnosis, and timing of intervention to remove atrial mass in patients with frailty and a fast-growing cardiac mass.

CMR detects extensive intracavitary thrombi as solitary clinical presentation of Antiphospholipid Syndrome: A case report.

Intracavitary thrombi are an important differential diagnosis of cardiac masses. Cardiac magnetic resonance imaging (CMR) allows their non-invasive characterization. This case highlights extensive cardiac thrombi detected by CMR as solitary presentation of antiphospholipid syndrome.

Mysterious Left Atrial Mass in a Patient With Metastatic Prostate Cancer.

Cardiac tumors (CTs) are a rare group of disorders that encompass a broad set of masses. They are subclassified into neoplastic and non-neoplastic lesions. Neoplastic lesions can be further subdivided into either primary cardiac tumors (PCTs) or secondary cardiac tumors (SCTs) which are metastasis to the heart. Cardiac myxomas are the most common pathological type of benign PCT followed by rhabdomyomas, papillary fibroelastomas, fibromas, lipomas, and leiomyomas. Here, we present a case of a patient with left atrial mass in the setting of stage IV prostate cancer. We have used transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) for characterization and differential generation. Our findings are presented in high-quality imaging and video and our top differentials include PCT, thrombi, and metastasis. Although a full diagnostic workup was not completed due to limitations in diagnostic tests available, metastasis to the heart could not be excluded due to the high staging and extensive sclerotic involvement of this malignancy. We emphasized the importance of multimodality imaging, e.g., TTE, TEE, cardiac magnetic resonance (CMR), and cardiac computed tomography (CT) in the workup of incidental cardiac masses and differential refinement.

Radiomics Feature Analysis Using Native T1 Mapping for Discriminating Between Cardiac Tumors and Thrombi.

RATIONALE AND OBJECTIVES: Accurate differential diagnosis is essential because cardiac tumors and thrombi have different prognoses and therapeutic approaches. Native T1 map provides an objective T1 time quantifications of cardiac mass without the need for a contrast agent. We examined the diagnostic performance of radiomics features for differentiating cardiac tumors from thrombi using cardiac magnetic resonance imaging T1 mapping technique compared to that of late gadolinium enhancement (LGE) imaging. MATERIALS AND METHODS: This retrospective study included 22 cardiac tumors and 21 thrombi of 41 patients who underwent cardiac magnetic resonance imaging from December 2013 to May 2018. Fifty-six radiomics features were extracted from native T1 images. The least absolute shrinkage and selection operator method was used for feature selection and rad score extraction. The diagnostic performance of the rad score was compared to that of the native T1 value (mean T1) and LGE ratio. RESULTS: The area under the receiver operating characteristic curve of the rad score was higher than that of the mean T1 and LGE ratio (0.98 vs. 0.86 vs. 0.82, p = 0.001). With the optimal cut-off value, the rad score showed sensitivity, specificity, and accuracy of 95.4%, 95.2%, and 95.2%, respectively. Combination of the rad score and mean T1 showed a significantly higher diagnostic performance than mean T1 (p = 0.019) or LGE ratio (p = 0.022). CONCLUSION: The rad score derived from native T1 maps can differentiate thrombi from tumors better than the mean T1 or LGE ratio. This is valuable for determining a treatment strategy for cardiac lesions in patients who cannot tolerate contrast agents.

Contrast echocardiography facilitates appropriate management of hospitalized patients with coronavirus disease 2019 (COVID-19) and suspected right ventricular masses: case series.

BACKGROUND: Coronavirus disease 2019 (COVID-19) infection is associated with a coagulopathy with high incidence of venous thrombo-embolism. However, bleeding risk is also significant, causing difficulty in initiating and adjusting anticoagulation therapy in case of suspected thrombi. Cardiac masses can be challenging to be identified properly in the context of this disease. The use of bedside contrast echocardiography (CE) can be of a great value in this situation decreasing procedure-related risk and allowing proper diagnosis and management of a cardiac mass. CASES SUMMARY: We present two cases who were admitted with severe COVID-19 infection. Both cases had additional risk factors for hypercoagulability. Un-enhanced echocardiography was performed and revealed right ventricular (RV) dysfunction with a suspected RV mass. The use of bedside CE could confirm a RV thrombus in the first case and exclude it in the second case. Hence, anticoagulation therapy could be adjusted accordingly in both patients. DISCUSSION: Coronavirus disease 2019 infection is associated with peripheral thrombo-embolism and cardiac thrombi. Given the critical condition of many patients affected by COVID-19, imaging for thrombo-embolic events is often restricted. With the use of bedside CE, cardiac masses may be correctly identified, aiding proper adjustment of anticoagulation therapy.

A Cardiac Amyloidosis Presentation: Atrial Mass Versus Thrombus.

Cardiac neoplasms are a rare finding of which a cardiac myxoma is the most commonly encountered. Therefore, a density identified in the left atrium commonly leads to the presumptive diagnosis of an atrial myxoma. However, other pathologies, such as atrial thrombi, can mimic in clinical presentation and appearance to a myxoma. Clinically, these pathologies may lead to obstructive symptoms such as syncope, palpitations, or sudden cardiac death. At present, echocardiography, magnetic resonance imaging, or computed tomography can be used to identify such masses, but fall short of identifying the primary cause. The management of atrial thrombi is not yet fully understood and definite recommendations have not been established. We present a case of an 87-year-old man complaining of syncopal episodes found to be secondary to an incidental intracardiac density resulting from age-related amyloidosis.

Thromboembolic Complications Following Tissue Plasminogen Activator Therapy in Patients of Acute Ischemic Stroke - Case Report and Possibility for Detection of Cardiac Thrombi.

Many reports focus on the probability of intracranial hemorrhage as a complication after recombinant tissue plasminogen activator (rt-PA) therapy. However, thromboembolic complications are not well discussed. We experienced a case in which severe thromboembolic complications occurred in the right radial and right ulnar artery. Arterial fibrillation was observed in this case. If multiple thrombi exist in the atrium or ventricle, multiple small embolic particles may appear following thrombolytic therapy, and that may be a potential risk of secondary thromboembolic complications due to incomplete dissolution of thrombi. Transesophageal echocardiography is a standard method to detect intracardiac sources of emboli in the case of arterial fibrillation. Transesophageal echocardiography is, however, an invasive method for patients with ischemic stroke during rt-PA therapy. High resolution enhanced CT could be a useful tool and may be a reliable alternative to transthoracic echocardiography. Careful assessment of thromboembolic complications following rt-PA therapy in patients with arterial fibrillation is needed. In this case report and mini review, we would like to discuss about the accurate diagnostic methods to detect cardiac or undetermined embolic sources and provide expedited stroke care. These embolic sources may be more readily discovered during rt-PA therapy within the limited therapeutic time window.

Biventricular Thrombi in a Patient With Heart Failure With Severely Reduced Ejection Fraction and Heterozygous Prothrombin 20210G/A and Homozygous Methylenetetrahydrofolate Reductase 677C/T Mutations.

Thrombus in the heart is known to be one of the many sequelae of anterior wall myocardial infarction, atrial fibrillation and coagulation disorders. However, biventricular thrombi are relatively rarely found, even in conditions with a high possibility of thrombus formation. We report the case of a 75-year-old-woman with newly diagnosed systolic heart failure secondary to a nonischemic cardiomyopathy, who was found to have large biventricular thrombi. Further coagulopathy work-up revealed that she was heterozygous for the prothrombin 20210G/A and homozygous for the methylenetetrahydrofolate reductase (MTHFR) 677C/T mutations. We, herein, review and discuss previous case reports and published literature regarding ventricular thrombosis and its treatment. To the best of our knowledge, this is the first case of biventricular thrombosis with prothrombin 20210G/A and MTHFR 677C/T mutations.

Non-bacterial thrombotic endocarditis in the right atrium caused by pectus excavatum.

BACKGROUND: Non-bacterial thrombotic endocarditis (NBTE) is an uncommon pathological situation, which involves the presence of bland, fibrin-platelet thrombi. It usually occurs at the endocardium of cardiac valves, in association with endothelial injury and a hypercoagulative state. However, NBTE on the endocardium at the right atrial free wall in a patient without any apparent hypercoagulative background is rarely reported. CASE PRESENTATION: A girl aged 4 years with severe pectus excavatum was referred to our hospital for treatment of a recurrent right atrial tumor. The tumor was removed concomitant with pectus excavatum repair. The tumor was revealed as recurrent thrombus. Pathological findings showed that NBTE caused by an operative scar on the endocardium of the right atrium and sustained rheological stress in the right atrium due to compression from pectus excavatum lead to recurrent thrombus formation. Three years after the discontinuation of anticoagulation therapy, no sign of thrombus formation was found. CONCLUSIONS: To our knowledge, this is the first report of NBTE related to an interaction between sustained rheological stress from cardiac compression and endocardial injury. In such patients, we recommend concomitant chest wall repair when the operative scar is present at the site of the rheological force.