Intracardiac Masses Flashcards
2 types of cardiac tumors
- Primary tumor of the heart - Rare!
- Metastasis of distant noncardiac primary tumor - 100-fold MC > primary tumors
- May be symptomatic or found incidentally
- In symptomatic pts, a mass can always be detected by echo, MRI, and/or CT
The ____ and ____ of the tumor determine the clinical findings, not the histopathology
anatomic location and size
endocardial manifestations of cardiac tumors
- Thromboembolism: cerebral, coronary, pulmonary, systemic
- Cavitary obliteration or outflow tract obstruction
- Valve obstruction and valve damage
- Constitutional manifestations
valvular manifestations of cardiac tumors
- Valvular damage, obstruction, or regurgitation
- Congestive heart failure
- Sudden death or syncope
pericardial manifestations of cardiac tumors
- Pericarditis
- Pericardial effusion
- Arrhythmias
- Tamponade
- Constriction
myocardial manifestations of cardiac tumors
- Arrhythmias, ventricular or atrial
- Conduction abnormalities
- ECG changes
- Systolic or diastolic left ventricular dysfunction
- Coronary involvement: angina, infarction
clinical manifestation types of a cardiac tumor
- endocaridal
- valvular
- pericardial
- myocardial
how to dx cardiac tumors
- abnml cardiac contour on CXR
- Echo - helpful but can miss ventricular wall tumors
- Cardiac MRI/gated CT is diagnostic procedure
management for cardiac tumors
- Surgical excision - mainstay; +/- radiation/chemo
- Transplant - alt for unresectable cardiac tumors when infiltration is too extensive for excision
most primary cardiac tumors are ?
benign; 75-95%
MC primary cardiac tumors
- cardiac myxoma
- papillary fibroelastomas
MC cardiac tumor in kids
rhabdomyomas
Typically occurs before the age 1
prevalence of myxoma
- 50% of benign cardiac tumors
- 30-60 y/o - avg 51
- sporadic and isolated
- <10% familial (autosomal dominant)- Avg 25 y/o; more likely to have multiple and recurrent tumors
- Pedunculated and gelatinous in consistency
- surface may be smooth, irregular, or friable
this description is for what primary cardiac tumor
myxoma
what type of myxomas associated w/ a higher risk of embolization
Friable or villous
what type of myxoma tends to present with obstructive cardiovascular symptoms
Larger tumors with a smooth surface
About 2/3 of myxomas occur where?
left atrium
Arise from endocardial surface of LA w/ a stalk attached to interatrial septum close to the fossa ovalis
which primary cardiac tumor presents with the “tumor plop”
- Caused by obstruction of MV opening by tumor
- An early diastolic extra heart sound
- Occurs later than opening snap of a stenotic MV and earlier than an S3, which can be difficult to distinguish with auscultation
myxoma
dx and tx for myxoma
-
dx: echo or pathology of embolic material
- Cardiac MRI can be a useful adjunct -
tx → surgical excision
- Recurrences can occur thus serial echo f/up is recommended
Look like a sea anemone, attached to the endocardial surface of the valves by a small pedicle
Papillary Fibroelastoma
Papillary Fibroelastoma affects which valve MC?
MC left-sided valves, AV>MV
- May also appear on the chordae, papillary apparatuses, left ventricular septum, left ventricular outflow tract, left ventricular free wall, and the left atrium
clinical manifestations of Papillary Fibroelastoma
cerebral embolism, myocardial infarction, sudden death, pulmonary embolism, and syncope
Solitary, circumscribed, encapsulated tumors with a wide range of size and weight
Lipoma
possible locations of a Lipoma
- Subendocardial protruding into cardiac chamber (MC)
- Arise in epicardial space and grow into the pericardial space
- Intramyocardial lesion
upon echo you see a “dumbbell” shaped sparing of fossa ovalis in lipomatous interatrial septal hypertrophy
what is this indicative of?
cardiac lipoma
cardiac fibromas are MC in who?
- Can occur at any age, but MC in pediatric (75%)
- 2nd MC benign pediatric cardiac tumor
fibromas can occur where in the heart, and where can it happen MC?
- Can occur in any chamber
- MC ventricular myocardium, esp anterior wall of the LV and interventricular septum
Typically large in size; 4 to 7 cm
Not distinctly encapsulated - Makes complete resection challenging
what type of primary tumor
fibroma
Result in sx of HF, ventricular arrhythmias, and sudden death d/t mass effect
where can rhabdomyomas occur?
- Occurs any chamber but usually spares the valves
- Commonly there are multiple tumors at one time
- Range in size from a few millimeters to a few centimeters and are white to yellow
management for rhabdomyoma
Unless the pt is symptomatic, surgical intervention is often unnecessary
Spontaneous regression is common
MC malignant primary tumor type
-sarcoma
MC malignant cardiac tumors in adults - 20-49y
what is the most common histologic subtype of malignant primary tumor, followed by what else?
- angioscarcomas
- rhabdomyosarcomas, fibrosarcomas, and osteosarcomas
malignant tumors are extensively ___ and ____ at time of diagnosis is common
infiltrative and metastasis
what are lymphomas?
- Primary cardiac lymphoma is extremely rare - 25% pts w/ lymphoma have cardiac involvement at autopsy
- Can involve any area of the heart
- Very infiltrative and quick to metastasize
- Very poor prognosis; mean survival of 7 months after diagnosis
Invasive in the pericardium
MC primary pericardial tumor
Mesothelioma
Involve most of parietal and visceral surfaces, with only superficial invasion of adjacent myocardium
Mesothelioma MC begins where in the heart
AV node
may result in heart block
mesothelioma of the heart is MC in who
MC in adults, males
NOT consistently linked to asbestos exposure
presentation and management of mesothelioma
- pericarditis, tamponade, or constriction
- Poor response with radiation and chemo; surgical pericardiectomy - palliative measure
Cardiac metastases occur how much more often than primary tumors of the heart
30x
Cardiac metastases often present as ?
pericardial effusions
Cancers with high likelihood of metastasis to the heart:
- Melanoma (MC)
- Lung CA
- Leukemia and lymphoma
- Renal cell CA
- Breast CA
- Liver and esophageal CA
Malignant cells from any single source can metastasize to the heart via ____ and can often _____
multiple routes
seed in multiple cardiac structures
modes of spread of secondary/metastatic cardiac tumors
- lymphatic and hematogenous spread
- direct local invasion from mediastinal structures
- extension of tumor thrombus into IVC (renal cell carcinoma)
Myocardial > coronary > intracavitary involvement occur uncommonly
Intracardiac thrombi develop as a result of
stasis of blood
Intracardiac Thrombus MC occurs where?
Left side - LA, LV (apex)
intracardiac thrombus may result in ____, such as CVA/TIA, mesenteric ischemia, acute limb ischemia
embolic events
dx/imaging for intracrdiac thrombus
echo
causes of LA thrombus
- A. fib (#1)
- LA appendage
- Mitral stenosis
causes of Left Ventricular Thrombus
- Dilated cardiomyopathy (#1)
- MI resulting in decreased apical wall motion
- Stress cardiomyopathy
Most LV thrombi are stable > LA thrombi after about how many days?
why?
30 days
they wall themselves off
The only long-term oral anticoagulant approved for intracardiac thrombus tx
-
warfarin/Coumadin x 3mo - only long-term oral anticoag approved
- pts hospitalized for start of warfarin, while bridging with heparin or Lovenox (LMWH)
- Goal of INR - 2.0-3.0
When do we use prophylaxis to prevent thrombus development?
Only in A. Fib!
Thrombectomy is indicated for intracrdiac thrombus if?
- undergo open-heart surgery for another reason
- Failure of anticoagulation
- Anticoagulation is CI
