TUTORIAL |
https://doi.org/10.5005/jp-journals-10089-0088 |
Right Atrial Mass and Three-dimensional Transesophageal Echocardiography
1,3Department of Cardiac Anaesthesia and Critical care, All India Institute of Medical Sciences (AIIMS), Delhi, India
2Department of Cardiac Anaesthesia, Institute of Postgraduate Medical Education & Research (IPGMER), Kolkata, West Bengal, India
Corresponding Author: Mohanish R Badge, Department of Cardiac Anaesthesia and Critical care, All India Institute of Medical Sciences (AIIMS), Delhi, India, Phone: +91 1126593858, e-mail: mohanish.badge11@gmail.com
Received: 18 November 2023; Accepted: 25 December 2023; Published on: 19 February 2024
ABSTRACT
A 19-year-old male, with history of hypothyroidism, presented with progressive dyspnea along with pedal edema and abdominal distention over 2 years. In the cardiology outpatient setting, transthoracic echocardiography (TTE) revealed pulmonary stenosis, tricuspid regurgitation (TR), dilated right atrial (RA), dilated right ventricle (RV), RV dysfunction and spontaneous echo contrast (SEC) in the RA. There was a sessile mass in the RA near the superior vena cava-right atrial (SVC-RA) junction. Computed tomography (CT) and magnetic resonance imaging (MRI) were not done as the mass was presumed to be a thrombus in view of it being sessile, not related to the interatrial septum, proximity to the RA appendage, and presence of SEC. The patient was diagnosed as having congenital pulmonary stenosis with concomitant TR and a thrombus in the RA. He was started on heparin for thrombolysis and referred to the cardiac surgical team.
How to cite this article: Badge MR, Senthil E, Kapoor PM, Right Atrial Mass and Three-dimensional Transesophageal Echocardiography. J Acute Care 2023;2(3):163–165.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient(s) for publication of the research details and related images.
Keywords: Right atrial, Right atrial mass, Three-dimensional transesophageal echocardiography
We recently encountered an unusual case of right atrial (RA) myxoma resembling a thrombus in a patient with congenital pulmonary stenosis. We would like to describe the diagnostic pitfalls encountered and the advantages of using three-dimensional (3D) transesophageal echocardiography (TEE) for the identification of the nature of the mass. Initial transthoracic echocardiography (TTE) showed valvular pulmonary stenosis with dilated right ventricle (RV) and RA. A cardiac mass in the RA was also seen. The sessile nature of the mass along with the presence of spontaneous echo contrast (SEC) and location near the RA appendage led to an initial interpretation of RA thrombus. The patient was scheduled for surgical removal of the thrombus along with pulmonary valvotomy. Initial TEE examination in the operating room revealed a mass in the RA (3.5 × 3.8 cm) with a broad base of attachment near the superior vena cava-right atrial (SVC-RA) junction (Fig. 1). A full volume 3D volume set of the mass was collected and stored. After atriotomy, the mass was found at the reported location, just that it had the consistency and texture of a myxoma rather than a thrombus. Retrospective analysis of collected 3D TEE volume data showed that the mass had a heterogenous surface texture, and few irregular calcifications in crop plane view through the mass, all findings pointing toward a tumor rather than a thrombus (Fig. 2).1 The higher resolution and detail afforded by 3D imaging enabled us to see the distinctive characteristics of a myxoma which were missed in the two-dimensional (2D) TEE analysis. Furthermore, 3D TEE enabled us to confirm the extent of the mass and its lack of mass effect on the tricuspid valve, which was slightly ambiguous with 2D imaging.
Fig. 1: Two-dimensional (2D) echocardiography in midesophageal four-chamber view with right side focus showing 3.8 × 3.5 cm mass attached to the superior wall of the RA with SEC
Fig. 2: Three-dimensional (3D) TEE volume set revealed a mass with a rough surface and heterogenous echotexture along with SEC; RA, right atrial
DISCUSSION
Cardiac masses present occasionally with unusual location or morphology and can pose diagnostic dilemmas for the clinician. The use of more advanced imaging like cardiac magnetic resonance imaging (MRI) is expensive and often hard to access in many places and as such is not feasible for routine evaluation. The increased availability of TEE and advancement in quality of TEE has helped in the general assessment of cardiac masses, not just in their location and morphology but also in their effects on cardiac function. 3D TEE is a big advancement in this direction, yet its full power is left unharnessed in unfamiliar hands due to a lack of training and/or experience. Aggeli et al. outlined a general diagnostic algorithm for cardiac masses based on clinical scenarios and TTE findings to suggest further evaluation modalities as required.2 They acknowledge the superiority of TEE, specifically 3D TEE but ultimately do not give sufficient importance to 3D TEE. This case shows the pitfalls of such an approach where the unusual presentation and location of the cardiac mass defies accurate diagnosis by TTE and even 2D TEE imaging. Pino et al. did an extensive review of the echocardiographic approach to cardiac masses and noted that 3D TEE allows for a more detailed evaluation, notably of the location and physical dimensions of the tumor. They also described how 3D TEE allows better tissue characterization and its relationship to adjacent structures such as valves.3
The broader availability and widespread use of 3D TEE will help in reducing the misdiagnosis of cardiac masses. Dujardin et al. showed how intraoperative TEE gave additional information and even altered surgical procedures in 8% of the cases in their study.4 It is not unreasonable to expect that real-time 3D TEE (RT3DTEE) will show similar incremental advantages over 2D TEE. This will help prevent unnecessary surgical exposure for the patient, as in the case reported by Shashikant et al., where an extracardiac cavernous angioma was misdiagnosed as an intracardiac mass.5
CONCLUSION
We would like to conclude that there are still many lacunae in our understanding of cardiac tumors and also that clinical history, location, and basic imaging can all confound the proper diagnosis of cardiac masses. The use of 3D is one incremental but significant step toward a more reliable diagnostic approach to intracardiac lesions. Better training and more experience with RT3DTEE can only improve the diagnosis and evaluation of cardiac masses. In addition, preoperative RT3DTEE can help avoid intraoperative surgical dilemmas.
THE FOLLOWING IS A TUTORIAL ON CARDIAC MASSES
Q1. What are the normal anatomic variants/devices in the RA that can be confused with intracardiac masses?
A: The following are the normal anatomic variants in RA that can be mistaken for an intracardiac mass—crista terminalis, Eustachian valve, Chiari network, pectinate muscle, lipomatous hypertrophy of septum, and pacing wires/catheters.
Q2. What are the normal anatomic variants/devices in the left atrial that can be confused with intracardiac masses?
A: The following are the normal anatomic variants in LA that can be mistaken for intracardiac mass—coumadin ridge and pectinate muscle.
Q3. What are the normal anatomic variants/devices in the RV that can be confused with intracardiac masses?
A: The following are the normal anatomic variants in the RV that can be mistaken for intracardiac mass—moderator band, pacing leads, intracardiac defibrillator, and pulmonary artery catheter.
Q4. What are the normal anatomic variants/devices in the left ventricle that can be confused with intracardiac masses?
A: The following are the normal anatomic variants in LV that can be mistaken for intracardiac mass—false tendon, left ventricular band, and hypertrophied papillary muscle.
Q5. What conditions predispose to the development of thrombus in the left atrial and how do you differentiate it from pectinate muscle?
A: Conditions predisposing to left atrial thrombus include atrial fibrillation, mitral or aortic valve stenosis, and myocardial infarction.6 Pectinate muscles are a series of parallel ridges across the anterior endocardial surface, including the appendage. Their synchronous movement and similar density with cardiac tissue distinguish them from the asynchronous movement of a thrombus.
Q6. When do you see a thrombus in the left ventricle? What is the role of contrast agents to aid in diagnosis?
A: Thrombus in LV can be seen post-acute myocardial infarction, dilated cardiomyopathies (ischemic and nonischemic) with low ventricular ejection fraction and heart failure.7 Rarely, it occurs in normal ventricular function with systemic inflammatory conditions, malignancies, blood dyscrasias, hypercoagulable states, and certain medications (tamoxifen, erythropoietin).8 Contrast agents produce contrast opacification to show the “filling defect” of the thrombus. Contrast perfusion echocardiography, owing to the vascularity of the tumor, can differentiate between a thrombus.9
Q7. When do you get thrombosis in the right heart?
A: Thrombus in the right heart can be found in atrial fibrillation, structural heart disease, cardiomyopathies, catheters in situ, pacemaker lead, and “thrombi-in-transit” from lower limbs/deep vein thrombosis.10
Q8. What are vegetations?
A: Vegetations usually appear as discrete, mobile, echo-dense masses, adherent to the upstream surface of a valvular leaflet or mural endocardium due to infective endocarditis.
Q9. What are the primary cardiac tumors and which is the most common benign cardiac tumor?
A: Tumors originating within the heart are primary cardiac tumors. Myxoma is the most common primary, benign cardiac tumor.
Q 10. What is a myxoma? Describe its characteristic features.
A: Myxoma is a benign cardiac tumor that usually arises from the left atrial, is pedunculated, and has a smooth surface attached to the interatrial septum at the region of fossa ovalis with a heterogenous echotexture.
Q11. What are primary malignant tumors in the heart?
A: The malignant tumors of the heart are angiosarcoma, rhabdomyosarcoma, mesothelioma, and fibrosarcoma.11
Q12. What are nonprimary cardiac tumors?
A: Cardiac tumors with origin outside the heart, that is, metastatic. They can spread to the heart by direct extension (lung, esophagus, breast), intravascular (renal, hepatic), or hematogenous route (lymphoma, melanoma, leukemia).11
ORCID
Elvis Senthil https://orcid.org/0000-0003-4686-7163
Poonam M Kapoor https://orcid.org/0000-0003-3102-5043
REFERENCES
1. Zaragoza-Macias E, Chen MA, Gill EA. Real time three-dimensional echocardiography evaluation of intracardiac masses. Echocardiography 2012;29(2):207–219. DOI: 10.1111/j.1540-8175.2011.01627.x
2. Aggeli C, Dimitroglou Y, Raftopoulos L, et al. Cardiac masses: the role of cardiovascular imaging in the differential diagnosis. Diagnostics (Basel) 2020;10(12):1088. DOI: 10.3390/diagnostics10121088
3. Pino PG, Moreo A, Lestuzzi C. Differential diagnosis of cardiac tumors: general consideration and echocardiographic approach. J Clin Ultrasound 2022;50(8):1177–1193. DOI: 10.1002/jcu.23309
4. Dujardin KS, Click RL, Oh JK. The role of intraoperative transesophageal echocardiography in patients undergoing cardiac mass removal. J Am Soc Echocardiogr 2000;13(12):1080–1083. DOI: 10.1067/mje.2000.107157
5. Shashikanth M, Nicola S, Yi C, et al. Right atrial cavernous hemangioma. Ann Card Anaesth 2020;23(3):335–337. DOI: 10.4103/aca.ACA_58_19
6. Meus R, Son M, Sobczyk D, et al. Prothrombotic state in patients with a left atrial appendage thrombus of unknown origin and cerebrovascular events. Stroke 2016;47(7):1872–1878. DOI: 10.1161/STROKEAHA.116.012856
7. Levine GN, McEvoy JW, Fang JC, et al. Management of patients at risk for and with left ventricular thrombus: a scientific statement from the American Heart Association. Circulation 2022;146(15):e205–e223. DOI: 10.1161/CIR.0000000000001092
8. Svendsen C, Pauley E, Stouffer GA. Left ventricular thrombus formation in the setting of normal systolic function. JACC Case Rep. 2020;2(10):1470–1474. DOI: 10.1016/j.jaccas.2020.05.027
9. Abdelmoneim SS, Pellikka PA, Mulvagh SL. Contrast echocardiography for assessment of left ventricular thrombi. J Ultrasound Med 2014;33(8):1337–1344. DOI: 10.7863/ultra.33.8.1337
10. Goh FQ, Leow AS, Ho JS, et al. Clinical characteristics, treatment and long-term outcomes of patients with right-sided cardiac thrombus. Hellenic J Cardiol 2022;68:1–8. DOI: 10.1016/j.hjc.2022.07.008
11. Tyebally S, Chen D, Bhattacharyya S, et al. Cardiac Tumors: JACC CardioOncology State-of-the-Art Review. JACC CardioOncol 2020;2(2):293–311. DOI: 10.1016/j.jaccao.2020.05.009
________________________
© The Author(s). 2023 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.