Ultrasonography in the assessment of primary myxofibrosarcoma in the left atrium: a case report.

BACKGROUND: Cardiac myxofibrosarcoma is a rare cardiac malignant tumor, whose diagnosis is challenging due to its rare and non-specific manifestations. Ultrasound is the most important tool for detecting cardiac tumors. Yet, its diagnostic value in cardiac myxoidfibrosarcoma is rarely reported. Herein, we summarized the ultrasonic manifestations of myxofibrosarcoma in a 72-year-old Han woman. CASE PRESENTATION: The patient presented with crushing chest pain without obvious inducement, lasting 3-5 min each time, which would be relieved after rest, accompanied by palpitation, chest tightness, shortness of breath, dizziness, and syncope. The electrocardiogram (ECG) suggested atrial fibrillation. Ultrasound found two moderate echogenic masses in the left atrium; one was about 48 × 31 mm in size, and the other was about 25 × 24 mm in size. The clinical diagnosis was atrial mass and atrial fibrillation. The patient underwent the operation of left atrial tumor resection + mitral valvuloplasty + atrial fibrillation radiofrequency ablation + left atrial appendectomy. The tumor was completely removed, and the patient did not receive radiotherapy or chemotherapy after surgery. The patient was reexamined by ultrasound at 6, 42, and 91 days after surgery, and no obvious abnormalities were found. On day 115, moderate echoic mass was detected on the posterior wall of the left atrium, nearing the mitral valve ring, with a size of about 28 × 23 mm. Currently, the patient is under follow-up care. CONCLUSION: As the most important examination method for cardiac tumors, cardiac ultrasound has good diagnostic and differential diagnosis value and can be used regularly due to its simplicity and safety. The diagnosis rate of cardiac myxofibrosarcoma can be greatly improved by summarizing the ultrasonographic manifestations of cardiac myxofibrosarcoma and differentiating them from other lesions.

An Incidental Finding at Transplant Assessment: Case Report.

A 43-year-old woman with chronic hypersensitivity pneumonitis was referred for lung transplant assessment. An echocardiogram as part of her work-up revealed a large left atrial myxoma, presenting a conundrum on how best to manage her combined pathology. Because of the level of pulmonary disease, early intervention to remove the myxoma was not thought be viable without postoperative support. Use of extracorporeal membrane oxygenation to bridge patients for lung transplant is feasible, yet risks increased perioperative mortality. We present the first reported case of simultaneous cardiac myxoma removal and lung transplant.

The Assessment of Cardiac Masses by Cardiac CT and CMR Including Pre-op 3D Reconstruction and Planning.

PURPOSE OF REVIEW: The purpose of this review is to (1) review the recent evidence examining the use of CT and CMR in the assessment of a suspected cardiac mass, (2) summarize the typical imaging features of the most common cardiac masses, and (3) examine the latest developments in the use of three-dimensional reconstructions and models in the preoperative assessment of a cardiac mass. RECENT FINDINGS: CMR can distinguish between tumors and non-tumor masses and between benign and malignant mass with a high degree of accuracy. CT and CMR are complementary tools in the evaluation of cardiac masses. CMR is the preferred initial imaging modality due to its versatile imaging planes and superior tissue characterization. CT better depicts calcification and has a higher spatial resolution compared with CMR, which is of particular importance in preoperative planning. CT also offers a valuable alternative in those with contraindications to CMR. Three-dimensional reconstructions, particularly of CT datasets, are a valuable adjunct in the preoperative assessment of a cardiac mass and may allow a better appreciation of the margins of the mass and its relationship with surrounding structures. Three-dimensional printing is an emerging technology which may be of additional value in selected patients with a cardiac mass.

Fulminant primary cardiac lymphoma with sudden cardiac death: A case report and brief review.

Primary cardiac lymphoma (PCL) is very rare, with the variable clinical manifestations potentially leading to a delayed diagnosis. PCL is usually detected incidentally through image studies, whereas the diagnosis can be confirmed via analysis of pericardial effusion, endomyocardial biopsy tissue, or surgical specimens. Although no standard therapy has been established for PCL, without treatment, the prognosis is grave, with the estimated overall survival being approximately 1 year. We report a difficult diagnosis and complicated case of fulminant PCL, which is the first comprehensively reported case of PCL with secondary hemophagocytosis. A man presented with progressive dyspnea for 3 weeks, and then sudden cardiac death with ventricular fibrillation occurred. After resuscitation, echocardiography revealed a thickened left ventricular wall and severe mitral regurgitation, and computed tomography showed a right atrial mass with diffuse myocardial lesions. PCL was confirmed through a pathological analysis of specimens collected during mitral valvuloplasty, which also implied extensive myocardial involvement. Bone marrow biopsy demonstrated no evidence of lymphoma involvement, but secondary hemophagocytosis was noted. Despite aggressive chemotherapy, the patient died of sepsis with multiorgan failure 26 days after the operation.

Right Anterolateral Minithoracotomy versus Median Sternotomy Approach for Resection of Left Atrial Myxoma.

BACKGROUND: Minimally invasive surgery has become the standard approach for several cardiac diseases. In this retrospective study, we compared right anterolateral minithoracotomy (RALT) with standard median sternotomy (SMS) for resection of left atrial myxoma (LAM). MATERIALS AND METHODS: From January 2009 to June 2015, the clinical data of patients who underwent RALT (n = 30) and SMS (n = 36) for resection of LAM in our hospital were collected. The preoperative clinical data and operative results were compared between the two groups. RESULTS: There were no significant differences in aortic cross-clamp and cardiopulmonary bypass time between the two groups. The total incision length was significantly shorter in RALT group compared with SMS group (p < 0.001). For RALT and SMS groups, respectively, the intensive care unit length of stay was 29.2 ± 6.5 versus 43.5 ± 6.9 hours (p < 0.001), and the postoperative hospital length of stay was 5 days (interquartile range [IQR]: 4-6) versus 8 days (IQR: 7-10) (p < 0.001). The total cost in RALT group was 27,000 RMB (IQR: 25,000-29,000) versus 33,000 RMB (IQR: 31,000-35,000) in SMS group (p < 0.001). There were no significant differences in mortality and postoperative complications between the two groups. CONCLUSION: RALT approach for LAM resection can be performed safely with favorable cosmetic outcome, accepted clinical results, and lower cost. It should be considered as a promising alternative to SMS and merit additional study.

Intrapericardial paraganglioma: The role of integrated advanced multi-modality cardiac imaging for the assessment and management of rare primary cardiac tumors.

N/A.

Cardiac Sarcoma Arising From Malignant Transformation of a Preexisting Atrial Myxoma.

A 49-year-old man presented with shortness of breath on exertion, orthopnea, and chest pain. On transthoracic echocardiography, a myxomatous mass was seen in the left atrium. A diagnosis of atrial myxoma was made and the patient underwent urgent surgical intervention. At operation, the mass, which extended into the anterior leaflet of the mitral valve, was excised. Histopathologic examination showed a primary cardiac sarcoma arising within a preexisting atrial myxoma. The patient received no further treatment and died 7 months postoperatively. We report the first case of a malignant transformation of an atrial myxoma to a cardiac sarcoma.

Computerized tomography angiography in preoperative assessment of intravenous leiomyomatosis extending to inferior vena cava and heart.

BACKGROUND: Intravenous leiomyomatosis (IVL) extending to inferior vena cava and heart is one of the most challenging conditions for surgical treatment. We explored the use of computerized tomography angiography (CTA) in preoperative assessment for this disease. METHODS: A cohort of 31 patients with IVL extending to inferior vena cava and heart were reviewed from the year 2002 to 2014, focusing on the preoperative CTA imaging characteristics and the surgical procedures in clinical treatment. RESULTS: All patients were diagnosed correctly combining the clinical medical history and CTA imaging. Thirteen patients had tumors confined within the inferior vena cava, and 18 patients had tumors intruding into the right heart. Furthermore, 15 tumors were located in the right atrium alone, and 3 tumors involved both the right atrium and the right ventricle. All patients had simple or multiple soft tissue masses from the pelvis, with 22 tumors extending into inferior vena cava through the iliac veins and 9 tumors through the ovarian veins. Three patients had tumors invading into lung and underwent tumor thrombus resection in the pulmonary artery. Patients received either one-stage surgery or two-stage surgery dependent on patient general condition and tumor status. All operations were successfully performed by multidisciplinary cooperation, including gynecology, cardiac surgery, and vascular surgery, without severe surgical-related complications or deaths. CONCLUSIONS: CTA imaging can present location, size, and full-scale extension pathway of IVL lesions, and can be used as first-line imaging technique in preoperative assessment, having great significance in making surgical plan and obtaining successful outcome.

Cardiac MRI-based multi-modality imaging in clinical decision-making: Preliminary assessment of a management algorithm for patients with suspected cardiac mass.

BACKGROUND: Cardiac masses are rare with high morbidity and mortality that challenging the management. The purpose of this study was to evaluate the potential role of cardiac-MRI based multi-modality imaging in the clinical decision-making for patients with cardiac mass. METHODS: From November 2011 to May 2014, 59 consecutive patients (33 females; mean age, 48.2 ± 21.1 [range, 0.6-85] years) with suspected cardiac mass were enrolled in this prospective single center study, underwent MRI based multi-modality imaging and were followed up for survival status. Management strategy (surgery, chemotherapy or observation) was based on patient's clinical status and cardiac mass imaging characteristics (location, morphology, hemodynamics, embolization risk, metastasis, and resectability). RESULTS: Using cardiac MRI, 39 patients were diagnosed with intra-cardiac neoplasm (28 benign, 11 malignant) and 20 with pseudo-tumors (13 thrombi, 4 cysts and 3 fat infiltration); 34 masses (23 neoplasms, 11 pseudo-tumors) were eligible for surgical removal, and 4 underwent PET-CT scan to further delineate characteristics and metastasis. Pathological examination revealed high accuracy of cardiac MRI in differentiating benign from malignant tumors (96%), and neoplasm from pseudo-tumors (100%). As for the 16 patients with cardiac neoplasm not surgically treated, the 9 with "benign" masses as per MRI-based multimodality imaging survived during follow-up, while all 7 with "malignancy" died; the 9 with pseudo-tumors not surgically treated also survived with good condition. The median follow-up period is 2 years (10 days-3 years). CONCLUSION: Cardiac MRI based multimodality imaging appears useful for risk stratification and clinical decision making for patients with suspected cardiac mass.

Intraoperative transesophageal echocardiography assessment of right atrial myxoma resulting in a change of the surgical plan.

Transesophageal echocardiography (TEE) is an important diagnostic tool. It provides structural and functional assessment of cardiac structures which can improve the overall outcome of the patient. We present a case with right atrial myxoma in which TEE helped to find the attachment of the mass so that overall surgical plan was changed.

Three-dimensional echocardiography in the assessment of cardiac tumors: the added value of the extra dimension.

Echocardiography is the most frequently used imaging modality in the assessment of cardiac tumors. Historically, this evaluation had been based on the analysis of 2-dimensional (2D) echocardiographic sectors of the heart. The information obtained from orthogonal tomographic planes from several acoustic windows was used in an attempt to mentally reconstruct a model of how the tumor would actually look in 3 dimensions and how it would relate to its adjacent structures. New technology using matrix-array-transducers has permitted the development of real-time three-dimensional echocardiography (RT3DE), bringing cardiac imaging to a new dimension. Now it is possible to capture and analyze the entire volume of a cardiac tumor in a single cardiac cycle. This new imaging modality provides valuable clinical information that empowers echocardiographers with new levels of confidence in the diagnosis of heart disease. This manuscript discusses the added value of this new technology in the echocardiographic assessment of cardiac tumors.

Coronary artery disease in patients with cardiac tumors: preoperative assessment by computed tomography coronary angiography.

We studied the diagnostic accuracy of computed tomography coronary angiography (CTCA) for the diagnosis of significant coronary artery disease (CAD) compared to conventional coronary angiography (CCA) in patients with primary cardiac tumors. Thirty-eight consecutive patients with primary cardiac tumors (27 females, 11 males; mean age 56+/-6 years, range 32-86 years) underwent dual-source CTCA and CCA. Significant stenosis was defined as diameter reduction >50%. CCA served as the standard of reference. The prevalence of significant CAD in the study population was 8% (3/38 patients). Five of 544 segments (0.9%) in 1/38 patients (2.6%) was considered of non-diagnostic image quality on CTCA because of motion artifacts. In a segment-based analysis taking not-evaluative segments as false-positive, sensitivity, specificity, positive and negative predictive value of CT was 100%, 99%, 70%, and 100%, respectively. Preoperative CCA could have been avoided in 95% (36/38) of the patients and CCA would have confirmed the CTCA diagnosis in 5% (2/38) of the patients. Our results indicate that CTCA provides a high diagnostic performance for diagnosing significant CAD in patients with primary cardiac tumors. CTCA may thus be used as a filter test prior to surgery.

Assessment of cardiac masses: magnetic resonance imaging versus transthoracic echocardiography.

OBJECTIVE: The purpose of this study is to compare the role of magnetic resonance imaging (MRI) with transthoracic echocardiography (TTE) for characterization of cardiac masses. METHODS: Twenty-three patients were examined with a 1.5T MRI Scanner and TTE for the evaluation of suspected intracardiac masses. MRI examinations were performed with a protocol of steady cine imaging, HASTE and 3D IR-FLASH sequence after administration of gadolinium chelate. All patients were examined with MRI within a period of 1-2 weeks after TTE. RESULTS: According to the results of MRI, 15 patients underwent cardiac surgery. All of the operated patients were proven to have cardiac tumors with no false positive diagnosis on MRI. In 3 of 8 unoperated patients who were diagnosed to have cardiac tumors on TTE, cardiac thrombi were identified on MRI. Two patients with Eustachian valve in the right atrium on MRI were misinterpreted as having cardiac masses on TTE. In one patient with known renal cancer, metastases were diagnosed within the myocardium on MRI. TTE demonstrated a mass in the left atrium in one patient with a history of myxoma operation, whereas MRI was able to show the paracardiac extension of the mass into pulmonary veins and lung metastases, which are indicators of malignant transformation. In one patient, a mediastinal mass compressing the left atrium on MRI was misinterpreted as an intracavitary lesion with TTE. CONCLUSION: Contrast enhanced MRI is a noninvasive method superior to TTE in diagnosis, differentiation, and detection of extension of cardiac masses.

Prospective assessment of multiple cardiac papillary fibroelastomas: an echocardiographic and surgical study.

Multiple cardiac papillary fibroelastomas (PFEs) are thought to account for less than 10% of patients with PFE. We aimed at evaluating the frequency and location of multiple PFEs and the reliability of transthoracic (TTE) and transoesophageal (TEE) echocardiography in diagnosing multiple PFEs. Twenty-six consecutive patients (52±14 years, 65% males) with pathologically confirmed PFE had 21 PFEs diagnosed by TTE, 33 by TEE, and 62 at surgery. Eight patients (31%) had multiple PFEs found either by TEE or at surgery. Aortic valve was involved in 75% of patients with multiple PFEs and left ventricle in 38% of patients. The sensitivity of TTE in diagnosing any PFEs was 51.3% and 76.9% for TEE. Our study emphasizes the high frequency of multiple PFEs, the need of TEE for all presumed PFE and the need for careful assessment of left-sided endocardial surfaces, especially of the aortic valve, during PFE excision.