Specialty in Internal Medicine, Plantation General Hospital, 401 Nw 42nd Ave, Plantation, FL 33317, Florida, United States
Received date: June 16, 2016; Accepted date: August 29, 2016; Published date: September 02, 2016
Citation: Adam MA (2016) The Cardiac Mass; Is it A Thrombus, Tumor or Vegetation? Take it in the Context of the Disease. J Clin Diagn Res 4:128. doi:10.4172/2376-0311.1000128
Copyright: © 2016 Adam MA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Background: Masses are common findings in echocardiography and cardiac imaging; largely confusing without surgical and pathological interventions for diagnosis. Method: Through case presentations and peer-reviewed publications, this paper elucidates a scientific methodology on how a clinician can arrive at a timely diagnosis by focusing on the respective properties of the mass on imaging. Results: Twenty-three cardiac masses and two imaging cases are delineated respectively to tumor, vegetation or emboli, as well as other findings. One of the masses is substantiated by histopathological analysis after additional assessment with transesophageal echocardiogram. Conclusion: With eminent symptoms and potentially perilous delay of treatment, a careful examination of cardiac masses provides numerous unique clues in helping the clinician expedite treatment.
Valvular vegetation; Infective endocarditis; Cardiac mass; Thrombus; Valvular disease
In every-day echocardiography, extra intracardiac structures namely in order of least to most common: tumor, vegetation, and thrombus are encountered and often easily confused without a pathological diagnosis. Sometimes sample anatomical specimens surgically excised are inevitably covered in blood products, and without histopathologic processes are difficult to diagnose (Figure 1A).
Hence to administer a timely treatment for in situ masses, it is necessary to wield a high pretest probability from the perspective of different acoustic windows obtained from transesophageal (TEE), transthoracic (TTE), multiplane imaging modalities as wells as from the patient’s clinical history. Using this approach, the table below unveils the most probable of the three of the named masses by fixating on their properties such as texture, and size variability .
A 36 years of old female on multi-drug regimen for end-stage renal disease, insulin dependent diabetes mellitus, systemic arterial hypertension and a history of lung transplant presents with new-onset worsening palpitations , and feeling of episodic impending doom (Figure 1B). Initial work up with cardiac troponins are negative, electrocardiogram showed non-specific T wave abnormalities in the lateral precordial leads, while cardiac enzymes were elevated at 0.05 (Table 1). Physical examination shows a patient who is anxious, afebrile with faint 1/6 holosystolic murmur without radiation to axilla and a delayed plop . Bedside echocardiogram in the emergency department was followed with a 2D echocardiogram (Figure 1C).
|Cardiac Masses||Comments on Features||Diagnosis|
|Apex of the LV a tapering regional cavity is predisposed
to stasis. In association with anterior infarcts, there is a
10-40% incidence of thrombus reported.
|Ventricular infarcts, aneurysms, dyskenesis, akinesis
form endothelial injuries which by Virchow’s triad
|In pseudo aortic stenosis (reduced EF) and true aortic
stenosis, stasis in the left ventrcle become precipitating
factors for thrombogenicity
|Non - prosthetic valve
mass on upstream side
|Vegetations are typically located on the upstream side
of the valve, are usually irregular grotesque shaped and
exhibit disordered motion not in pattern with the valve
|Mass with severe valvular
|Unlike thrombi, most vegetations rarely cause stenosis.||Vegetation|
|Mass in cardiomyopathy||There is a 1.6-3.5% incidence of thromboembolic events in patients with CHF stage II-IV for which several studies indicate no benefit from anticoagulation.||Thrombus|
|Rheumatic valvular mass||M protein from Group A Streptococcuilicits an immune
cascade leading to disruption of valvular endothelium
and the valve basement membrane damage with erythrocyte
mitral valve mass
|There is a high occurrence of thrombus formation on
mechanical valves,while thrombus on bioprosthetic
valves are rare.
aortic valve mass
|Thrombus are more likely on mechanical mitral valves,
pannus formation occurs frequently on prosthetic aortic
valves. Pannus are chronic fibrous tissue growth
mostly flat and non-mobile and non-sessile.
|Mass on early
|Non-endothelized sewing rings and suture materials on the
ring is adhesive to blood prodcts.
|Mass on AICD or
|Thoracotomy and device insertion predisposes to vegetation
most of which attach to the electric lead.
|RA or LA appendage
|Morphologies of both appendages, have been associated with
erythrocyte sludge formation and eventual thrombogenesis.
|Libman Sacks verrucous non-bacterail thrombotic endocarditis
are common in this herpercoagulableanticardiolipin syndrome
|Myxoma, the most common cardiac mass located in the LA.
Thrombus can mimic myxoma even in anticoagulated
|Line related mass||While you will suspect that line-related masses are infectious in
etiology, on the contrary lines cause more thrombus. Certain
factors such as: oscillating motion of the line, chemotherapeutic
agents, and choice of specific line material can correlate
|Echogenic mass in
|One typical example of right-sided masses. Bacteremia and
endothelial mass or mass on valves are pointers to endocarditis
Using the modified Dukes criteria in prosthetic valve is helpful
in arriving at the diagnosis.
|Simultaneous biventricularapical obliterating masses||Cardiac involvement in hypereosinophilia affects both the left and
right sides with fibrotic fibrin formation, with wall damage and
|Mass on papillary
|Second most common cardiac benign tumors. Attachment usually
contiguous with valve leaflet. Mostly found on the aortic valve
possibly obstructing the outflow tract.
|Mass in a dilated LA.||Structural dilatation in the LA associated with poor forward
flow is associated with thrombus formation.
|Mass in SLE||Libman-Sacks Vegetation are sterile growth on valvular structures
in autoimmune lupus erythematosus. They, like other vegetations
can be associated with severe regurgitation.
|Recent MI or CABG
|In certain cases of hibernating myocardium post bypass graft, and
ventricular infarcts there is a risk for blood stasis.
|Adjacent regional wall mass
post valvular surgery
|Suturing and prosthetics valves cause artifacts. Shadowing artifacts can be mistaken for masses hence need
formultiplane views and parameters for better identification.
|Pulmonary vein mass||TTE is poor modality for detecting pulmonary emboli. Most
masses seen in the proximity of the pulmonary valve should
be seen in the context of the RVSP, and clinical symptoms such
as hemoptysis for possible neoplastic migration or embolism
|Severe TV regurgitation||Patient with flushing, wheezing and diarrhea should raise
suspicion for malignancy. The 5HIAA disease affects the TV first,
except in septal defects without a closure – left heart valves
Table 1: This table is only a guide in addressing cardiac masses.
The ultimate diagnosis, however, depends on their bacteriologic and microscopic properties . In all cases of suspected thrombus or pannus, vegetation should be excluded in the diagnosis. In addition, markers such as d-dimer, fibrin, prothrombin fragments, and serum levels of von Willebrand factor can be pointers to thrombus formation, while auto-immune markers are elevated in SLE . Sometimes relentless search can end up to PCR in the diagnosis of marantic nodules such as in Hodgkin’s (Figure 2).
A careful examination of the images in the case demonstrates a well-defined rounded mass freely oscillating ipsilateral to the flow direction . The 2D video images also show the mass coursing the motion of the valve. TEE and the pathologic diagnosis confirmed a thrombus (Figure 5).
42 years old male referred for evaluation for valvular heart disease with history of valve replacement. Overall, the left ventricular systolic function is preserved with ejection fraction of 65-70%, with moderate to severe concentric left ventricular hypertrophy and a restrictive filling pattern . The aortic valve showed obstructed mechanical prosthetic valve with a large mass noted causing severe aortic stenosis with peak/ mean pressure gradient 120 mmHg/70 mmHg. The estimated aortic valve area by the continuity equation 0.9 cm2 (Figure 3). The tricuspid valve had mild regurgitation with the right ventricular systolic pressure estimated at 65 mmHg .
While prosthetic valves have some inherent degree of obstruction, a close look at this view reveals a lesion on the valve . TEE confirmed the diagnosis. While transthoracic echocardiogram without contrast has 85% sensitivity in detecting intracavitary masses, the transesophageal procedure improves the diagnostic accuracy to about 95%, especially if the location is in the atrial appendage . Patient was administered thrombolysis. Post treatment echocardiogram showed aortic valve stenosis with a better peak/mean pressure gradient of 77/40 mmHg with thrombus no longer seen and the right ventricular systolic pressure estimated at 35-40 mmHg (Figure 4). And normal proximal aortic diameter [11,12].
The mass in the second case was also a thrombus befitting its location on a mechanical aortic valve . The clinician administered thrombolysis without surgical intervention or microscopic diagnosis based on most the criteria cited in the table above .
Cardiac masses either symptomatic or incidental are common findings in echocardiography and are problematic in precise diagnosis without intricate probing. While well-timed treatment is necessary, it is also absolutely essential to avoid administration of wrong treatment which could potentially be lethal to the patient. For a judicious diagnosis and treatment, characteristics such as regional location, mass morphology, clinical syndrome, and wave with the valve excursion are a few of the numerous clues to guide the clinician in the right direction.
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