European Journal of Cardio-Thoracic Surgery Advance Access published March 19, 2015
CASE REPORT
European Journal of Cardio-Thoracic Surgery (2015) 1–3 doi:10.1093/ejcts/ezv098
Left ventricular apical masses: distinguishing benign tumours from apical thrombi Bilal H. Kirmania,*, Sukumaran Binukrishnanb, John R. Gosneyc and D. Mark Pullana a b c
Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK Department of Radiology, Liverpool Heart and Chest Hospital, Liverpool, UK Department of Pathology, Royal Liverpool University Hospital, Liverpool, UK
* Corresponding author. Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L13 3PE, UK. Tel: +44-151-2281616; e-mail: [email protected] (B.H. Kirmani). Received 3 November 2014; received in revised form 30 January 2015; accepted 17 February 2015
Abstract Differential diagnoses for cardiac left ventricular apical masses presenting following acute myocardial infarction include thrombi and cardiac tumours. We present two such cases and the multidisciplinary assessment that is required to assist with diagnosis. Keywords: Intracardiac myxoma • Thrombosis • Heart ventricles • Magnetic resonance imaging • Echocardiography
INTRODUCTION
CASE PRESENTATIONS
A left ventricular (LV) thrombus is common following myocardial infarction, with an incidence of between 7 and 46% [1]. Peak incidence is within 2 days of the infarct and their presence is an independent predictor of mortality. In the absence of significant embolic phenomena, medical management with anticoagulation is usually considered sufficient, with surgery indicated for strokes or other circulatory emboli refractory to heparin therapy [2]. Ventricular thrombi are most commonly diagnosed in the first instance by echocardiography, but this modality may be inconclusive in up to 46% of studies. Cardiac magnetic resonance (MR) imaging, in contrast, has a sensitivity of 88% and a specificity of 99% for LV thrombus [1]. Primary tumours of the heart are rare, with an incidence of between 1.7 and 190 per 100 000 at unselected necropsy, the majority of which are benign [3]. Cardiac myxomata account for approximately half of these, occurring most frequently in the atria (75% left atrium and 20% right atrium), and rarely in the ventricles (3–4% on either side). Other benign primary cardiac tumours include papillary fibroelastomas, fibromas and lipomas. Coronary angiography can be useful to distinguish between thrombus and tumour if the neoplasm shows true vascularity, but MR imaging is considered the gold standard for distinguishing myxomas from thrombus. Papillary fibroelastomas are less solid than myxomas, however, and the multiple papillary fronds that exhibit a sea-anemone appearance when immersed are better visualized ‘shimmering’ with the temporal resolution of echocardiography. Myxomas tend to have high signal intensity on T2-weighted MR images although the presence of calcification or haemosiderin may affect this [4] (Fig. 1).
Case 1 A 72-year old lady with type 2 diabetes mellitus, hypertension, hypercholesterolaemia and a 40 pack-year history of smoking presented with new onset central chest pain and shortness of breath. Clinical examination was unremarkable and electrocardiogram showed normal sinus rhythm with T-wave inversion in aVL only. Her Troponin I came back at 3.68 ng/ml (normal
CASE REPORT
European Journal of Cardio-Thoracic Surgery (2015) 1–3 doi:10.1093/ejcts/ezv098
Left ventricular apical masses: distinguishing benign tumours from apical thrombi Bilal H. Kirmania,*, Sukumaran Binukrishnanb, John R. Gosneyc and D. Mark Pullana a b c
Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK Department of Radiology, Liverpool Heart and Chest Hospital, Liverpool, UK Department of Pathology, Royal Liverpool University Hospital, Liverpool, UK
* Corresponding author. Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L13 3PE, UK. Tel: +44-151-2281616; e-mail: [email protected] (B.H. Kirmani). Received 3 November 2014; received in revised form 30 January 2015; accepted 17 February 2015
Abstract Differential diagnoses for cardiac left ventricular apical masses presenting following acute myocardial infarction include thrombi and cardiac tumours. We present two such cases and the multidisciplinary assessment that is required to assist with diagnosis. Keywords: Intracardiac myxoma • Thrombosis • Heart ventricles • Magnetic resonance imaging • Echocardiography
INTRODUCTION
CASE PRESENTATIONS
A left ventricular (LV) thrombus is common following myocardial infarction, with an incidence of between 7 and 46% [1]. Peak incidence is within 2 days of the infarct and their presence is an independent predictor of mortality. In the absence of significant embolic phenomena, medical management with anticoagulation is usually considered sufficient, with surgery indicated for strokes or other circulatory emboli refractory to heparin therapy [2]. Ventricular thrombi are most commonly diagnosed in the first instance by echocardiography, but this modality may be inconclusive in up to 46% of studies. Cardiac magnetic resonance (MR) imaging, in contrast, has a sensitivity of 88% and a specificity of 99% for LV thrombus [1]. Primary tumours of the heart are rare, with an incidence of between 1.7 and 190 per 100 000 at unselected necropsy, the majority of which are benign [3]. Cardiac myxomata account for approximately half of these, occurring most frequently in the atria (75% left atrium and 20% right atrium), and rarely in the ventricles (3–4% on either side). Other benign primary cardiac tumours include papillary fibroelastomas, fibromas and lipomas. Coronary angiography can be useful to distinguish between thrombus and tumour if the neoplasm shows true vascularity, but MR imaging is considered the gold standard for distinguishing myxomas from thrombus. Papillary fibroelastomas are less solid than myxomas, however, and the multiple papillary fronds that exhibit a sea-anemone appearance when immersed are better visualized ‘shimmering’ with the temporal resolution of echocardiography. Myxomas tend to have high signal intensity on T2-weighted MR images although the presence of calcification or haemosiderin may affect this [4] (Fig. 1).
Case 1 A 72-year old lady with type 2 diabetes mellitus, hypertension, hypercholesterolaemia and a 40 pack-year history of smoking presented with new onset central chest pain and shortness of breath. Clinical examination was unremarkable and electrocardiogram showed normal sinus rhythm with T-wave inversion in aVL only. Her Troponin I came back at 3.68 ng/ml (normal
