Intracardiac Masses Flashcards
What are essentials of diagnosis of intracardiac masses?
- Rare but critical
- Confirmation requires tissue biopsy (but H&P and imaging hold valuable diagnostic clues)
- Surgical excision is mainstay of treatment
What are the 2 types of intracardiac tumors?
Primary and metastasis
If a patient is symptomatic, a cardiac mass can almost always be detected by what?
Echo, MRI, and/or CT
What determines the clinical findings of cardiac tumors?
Anatomic location and size
What are characteristics of a endocardial cardiac tumor?
- Thromboembolism: cerebral, coronary. pulmonary, systemic
- Cavitary obliteration or outflow tract obstruction
- Valve obstruction and valve damage
- Constitutional manifestations
What are characteristics of a valvular cardiac tumor?
- Valvular damage, obstruction, or regurgitation
- Congestive heart failure
- Sudden death or syncope
What are characteristics of a pericardial tumor?
- Pericarditis
- Pericardial effusion
- Arrhythmias
- Tamponade
- Constriction
What are characteristics of a myocardial cardiac tumor?
- Arrhythmias, ventricular or atrial
- Conduction abnormalities
- Electrocardiographic changes
- Systolic or diastolic left ventricular dysfunction
- Coronary involvement: angina, infarction
How are cardiac tumors diagnosed?
- May be discovered as abnormal cardiac contour on CXR
- Echo (but may miss ventricular wall tumors)
- Cardiac MRI/gated CT = diagnostric procedure of choice
How are cardiac tumors managed?
- Surgical excsision = mainstay, especially if symptomatic
- Some require radiation or chemo
- Cardiac transplantation for unresectable cardiac tumors or extensive infiltration
What is the epidemiology of benign primary tumors?
- Rare (.02%)
- Cardiac myxoma = traditional MC tumor in adults
- Now papillary fibroelastomas thought higher frequency
- Rhabdomyomas MC in kids
What is the epidemiology of myxomas?
- 50% of benign cardiac tumors
- Usually between 30 and 60 years old, mean age at diagnosis = 51
- Familial autosomal dominant mean age = 25 and more likely have multiple recurrent tumors
What are characteristics of myxomas?
- Pedunculated and gelatinous consistency
- Surface smooth, irregular, or friable
What are friable or villous myxomas associated with? Larger myxomas?
- Friable or villous = higher risk of embolization
- Larger tumors = obstructive cardiovascular symptoms
How do the majority of myxomas present?
- In L atrium with stalk attached to interatrial septum (near fossa ovalis)
- Presents with tumor plop
What is a tumor plop?
- Obstruction of mitral valve opening by tumor
- Early diastolic heart sound
Later than opening snap of a stenotic mitral valve and earlier than S3
How is a myxoma diagnosed?
- Echo or pathology of embolic material
- Cardiac MRI = adjunct
How is a myxoma treated?
Surgical excision
What is the epidemiology of a papillary fibroelastoma?
- 8% of cardiac tumors
- Usually patients >60
- Also called papillary endocardial tumor, cardiac papilloma, or giant Lambl’s excrescence
What are characteristics of papillary fibroelastoma?
- Looks like sea anemone
- Attaches to endocardial surface of valves by pedicle
- MC left-sided valves, AV > MV
what are clinical manifestations of papillary fibroelastoma?
- Cerebral embolism
- Myocardial Infarction
- Sudden death
- Pulmonary embolism
- Syncope
What are characteristics of lipomas?
Account for 8% of primary cardiac tumors
* Solitary, circumscribed, encapsulated with wide range of size and weight
* Location: subendocardial protruding into cardiac chamber, arise in epicardial space and grow into pericardial space, or intramyocardial lesion
What is the epidemiology of fibroma?
- More commonly in pediatric population
- Second MC benign pediatric cardiac tumor
What is the location of fibromas?
- Any chamber
- MC ventricular myocardium, especially anterior wall of LV and interventricular septum
What are characteristics of fibromas?
- Typically large (4-7 cm)
- Not encapsulated
What do fibromas result in?
- heart failure
- ventricular arrhythmias
- sudden death due to mass effect
What is the usual location of rhabdomyomas?
- any chamber but spares the valves
- typically multiple at one time
how is rhabdomyoma treated?
- Usually not treated unless symptomatic
What ending should you keep an eye out for as malignant?
sarcoma + cardiac lymphomas, epitheliod hemangioendothelioma, malignant pleomorphic fibrous histiocytoma, malignant mesothelioma
What is the epidemiology of sarcoma?
- majority of primary cardiac malignancies and MC malignant in adult
- MC age 20-49
- Angiosarcomas MC subtype
What are characteristics of sarcomas?
- Extensive infiltration and metastasis at time of diagnosis common
- Very poor prognosis :(
Where is mesothelioma commonly located?
- “DUAL IDENTITY”
- Invasive in pericardium, most parietal and visceral surfaces encasing with only superficial invasion of adjacent myocardium
- Begin in AV node and may result in heart block
Who more commonly gets mesothelioma?
Adult men
How does mesothelioma present?
- Pericarditis
- Tamponade
- Constriction
what can be used as a palliative measure for mesothelioma?
surgical pericardiectomy
How do cardiac metastases often present?
Pericardial effusions
Do cardiac metastases or primary tumors of the heart occur more frequently?
Cardiac metastases
What cancers have high likelihood of metastasis to the heart?
- Melanoma
- Renal cell CA
- Lung CA
- Breast CA
- Leukemia and lymphoma
- Liver and esophageal CA
How can malignant cells spread to the heart?
- Lymphatic and hematogenous spread
- Direct local invasion from mediastinal structures
- Extension of tumor thrombus through inferior vena cava
- Myocardial –> coronary –> intracavitary involvement occur uncommonly
Why do intracardiac thrombus develop?
Stasis of blood
Where are intracardiac thrombi most common?
Left side of heart
What can intracardiac thrombi cause?
Embolic events such as CVA/TIA, mesenteric ischemia, acute limb ischemia
How is diagnosis of intracardiac thrombus made?
By echocardiogram
What are causes of left atrial thrombus?
- Afib
- Left atrial appendage
- Mitral stenosis
What are causes of left ventricular thrombus?
- Dilated cardiomyopathy
- MI resulting in decreased apical wall motion
- Stress cardiomyopathy
Most more stable than LV thrombi after 30 days because wall self off
How is intracardiac thrombus managed?
- Anticoagulation prophylaxis in a. fib
- Warfarin only approved oral long term
- Thrombectomy if open heart surgery, failure/CI to anticoag
What is the goal INR for warfarin use for intracardiac thrombi? How long should it be used?
2.0 to 3.0
at least 3 months
Patients hsould be hospitalized for initiation of warfarin while bridging with heparin or lovenox
