Tumors Rumors and Bad Humors Flashcards by Tim Montrief

Where do angiosarcoma originate in heart most often?

Right Atrium

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Where do fibroma originate in heart most often?

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Where do mesothelioma tumors originate in heart most often?

Pericardium

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Where do rhabdomyoma tumors originate in heart most often?

RV = LV

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Where do papillary fibroelastoma originate in heart most often?

Mitral Valve

Aortic Valve

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Rhabdomyoma are associated with what disease?

Tuberous Sclerosis

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Where is the most common place to find a myxoma?

Left Atrium

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What is the most common malignant tumor of the heart?

Metastatic

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What is the most common cardiac neoplasm in adults?

Myxoma

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What is the most common sarcoma tumor of the heart?

Angiosarcoma

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What is the most common metastatic cancer that has cardiac involvement?

Melanoma

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What is the most common tumor found in the vena cava?

Renal Cell Carcinoma

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What % of Primary Cardiac Tumors are benign?

75%

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What % of Primary Cardiac Tumors are malignant?

25%

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What is the most common primary cardiac benign tumors?

Myxoma

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Other than sarcomas, what is the 2nd most common malignant cardiac tumors?

Lymphomas

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What is the typical age group of myxoma?

30 - 60 year olds (Middle aged)

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What is the typical gender where myxoma are found?

Women > Men

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What is the location where myxomas are commonly found?

LA (75%)
RA (23%)
LV/RV (2%)

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Where are the myxomas commonly attached in the atriums (Left > Right)

Fossa Ovalis

Depression in the right atrium of the heart, at the level of the interatrial septum, the wall between right and left atrium. The fossa ovalis is the remnant of a thin fibrous sheet that covered the foramen ovale during fetal development.

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What are myxomas characterized as?

Protruding “fronds” of tissue or “Grape cluster” appearance

Frond: the leaf or leaflike part of a palm, fern, or similar plant

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Ventricular Myxoma:

More common in what population?

Women and Children (Multiple/Familial)

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Where are lipomas found in the heart (usually)?

Extramyocardial

Subpericardial

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What is lipomatous Hypertrophy?

Lipomatous hypertrophy of the interatrial septum (LHIS) is a relatively uncommon disorder of the heart characterized by benign fatty infiltration of the interatrial septum.

It is commonly found in elderly and obese patients as an asymptomatic incidentally discovered finding.

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Where are fibroelastomas traditionally seen?

**Downstream side of valve** (LV side of MV or Aorta side of AV)

What are the echo characteristics of **fibroelastomas**?

Well demarcated homogenous texture Small Mobile stalk Single vs. Multiple

What are the two most common types of primary malignant cardiac tumors?

1. Sarcoma (95%) 2. Lymphoma (5%)

What are the two most common type of sarcomas found in the heart?

1. Angiosarcoma 2. Rhabdomyosarcoma

What populaton is angiosarcomas most common?

Middle aged men

Where are angiosarcomas most common found?

What is the most common cardiac malignancy in pediatrics?

**Rhabdomyosarcoma**

Where are rhabdomyosarcomas found?

Ventricular Wall

Which is more common, primary or secondary cardiac tumors?

Seconary \> 20x more common

What is the most common primary source of secondary cardiac tumors?

1. Lung 2. Breast 3. Melanoma 4. Leukemia 5. Lymphoma

In malignant melanoma, what % of these patients have tumors in the heart?

50%

What is seen here in the image?

"Charcoal" view of the heart where tumor is on the pericardial space

Answer the question

**Carcinoid Heart Disease** - Funnel shaped leaflets don't open or close well

What is the most common cause of acquired pulmonic stenosis is what?

**Carcinoid Heart Disease**

What % of carcinoid patients will develop carcinoid heart disease?

\>50%

Where do carcinoid heart disease patients usually have metastatic disease?

**Hepatic Mets** (Large amounts of serotonin) Reach right heart before inactivated by monoamine oxidases in the lungs

What happens to the leaftlets in carcinoid heart disease?

Leaflets appear **thickened** and **shortened** (Progression they become retracted and hypomobile)

What is found in Carcinoid Heart Disease on the TV?

Early peak velocity nad steep decline "Dagger" Shaped profile

What is seen before the left atrial appendange here?

Left Atrial Appendage Membrane

Which is more common in Carcinoid Heart disease: TS or PS?

**PS \> TS** (Tricuspid valve has a huge annulus and much bigger than pulmonic valve

What would be an indication for surgery of a patient with pulmonic stenosis?

PS Gradient \> 10 mmHg

PR is present in **what percent** of patients with a normal pulmonic valve in presence of carcinoid heart disease?

40-78%

What 3 scenarios would is be feasible to have left sided cardiaac involvement from carcinoid disease?

1. **PFO** (Intracardiac shunts) 2. **Extensive primary bronchial carcinoid** 3. **High tumor secretions** or poorly controlled disease overwhelming capactiy of the lungs (Overcomes the mono-amine oxidase ability)

In a patient with carcinoid right sided heart disease, is a balloon valvuloplasty recommended?

No because of TR and PR

What are the 2 considerations in mechanical and bioprosthetic valve replacements for carcinoid disease

**Mechanical** 1. *_Less_* degeneration from carcinoid plaques 2. *_Higher_* Thrombotic risk **Bioprosthetic** 1. *_More_* degeneration from carcinoid plaques 2. *_Lower_* Thrombotic risk

What cardiac conditions are associated with Epstein anomalies?

1. Intracardiac Shunts (secundum ASD) 2. WPW (Tachyarrythmias)

***_Epstein Anomaly:_*** What is **malformed**?

TV and RV

Epstein Anomaly: What is the cause?

**Failure of delamination** (splitting of tissue by attachment of inner layer during embryological development)

What two leaflets are involved in Epstein anomaly? What do they look like?

**Septal** and *_Anterior_* **Septal** = Apically displaced *_Anterior_* = Redundant with fenestrations "Sail" extending into the RV

Comment on the mitral valve insertion in Ebstein Anomaly?

**Anterior Leaflet = Located More towards base of the heart** (Compared with the septal leaflet of the tricuspid valve)

What is the diagnostic value for Ebstein anomaly?

\>8 mm/m² BSA of the insertion of the septal leaflet from the insetion point on the mitral valve leaflet

What can happen to the LV in Ebstein Anomaly?

**LV Non-compaction** phenotype of hypertrophic ventricular trabeculations and deep interventricular recesses. It has been hypothesized to result from arrest of normal myocardial compaction during embryogenesis

What is this?

**Cor triatriatum dexter** is a rare congenital heart anomaly where the right atrium is divided into two chambers by a membrane.

Cor triatriatum dexter is caused from what?

Failure of resorption of common pulmonary veins during embryogenesis

Which is more common: Cor triatriatum dexter or Cor triatriatum sinister?

**Sister (left sided)** = More common

If you find Cor triatriatum dexter, what are the salient points that you need to keep in mind to look for on echo?

1. Flow Obstruction presence using doppler? 2. Evaluate Pulmonary Venous and Atrial Septal Anatomy 3. Look for associations (See next card)

Cor triatriatum dexter What 3 things is associated with this disorder?

1. ASD 2. MR 3. Persistent LSVC

What is seen here?

**Cor triatriatum sinister** (Top *_dorsal chamber_* receives pulmonary blood flow) (Bottom *_ventral chamber_* with green arrow = LAA and MV located here

**Cor triatriatum sinister** causes what potential problem?

LV inlet obstruction leading to mitral stenosis

Why is cor triatriatum sinister a surgical dilemma if found incidentally?

Exposes patient to risk of **open-chamber procedure**

What can Cor triatriatum dexter be confused with?

**Eustachian Valve** (separates during cardiac cycle)

Identify numbers 1

1 = Pectinate Muscles

Identify number 2 in the image

2 = Crista Terminalis

Identify 3 in the image

Right Atrial Appendage

How many lobes does the LAA of a normal human heart consist of?

**Can have 1-4** 1 = 20% 2 = 54% 3 = 23% 4 = 3%

Why is there a risk of stroke after cardioversion even if the appendage is clean?

Atrium is stunned and stroke risk still possible for 10 days

What can lipomatous hypertrophy be associated with?

**Atrial Arrythmias**

In addition to empyting velocities, what can left atrial thrombi be associated with?

**Spontaneous Echo contrast**

What is the Virchow Triad?

1. Stasis 2. Endothelial Dysfunction 3. Hypercoaguloable state

What is seen in the image here?

chiari network

Where does the chiari network originate?

Eustachian Valve

What are chiari networks associated with? (2 things)

1. PFO 2. Atrial Septal Aneurysm

What can Chiari networks be involved in the pathogenesis of? (3 things)

1. Thromboembolic disease 2. Arrythmias 3. Entrapment of percutaneous devices

What is the Eustachian Valve a remnant of?

Embryological Remnant of **Sinus Venosus**

What exactly is the **chiari network**?

Fibrous reticulum with multiple threads inserting onto the anterior surface of the Eustachian valve, posterior wall of the ostium of the IVC as well as the crista terminalis

What is the most common cause of thrombi of the RV?

Peripheral vein thrombus or indwelling catheter

What echo modality is better to image LV thrombus: TTE or TEE?

TTE more sensitive

What does the moderator band carry?

The moderator band is important because it **carries part of the right bundle branch of the atrioventricular bundle** of the conduction system of the heart to the anterior papillary muscle. ## Footnote This shortcut across the chamber of the ventricle ensures *_equal conduction time in the left and right ventricles, allowing for coordinated contraction of the anterior papillary muscle._*

What is seen here in the LV?

False Tendon

What are false tendons?

**Fibrous muscular bands stretching across the LV from ventricular septum to papillary muscle or LV free wall** No connection to vaalves Single/Multiple

Are false tendons clinically significant?

What is seen in this image?

Right Atrial Appendage Thrombus

If you have a Right Atrial Appendage clot, what do you need to tell the surgeon

**Recommend a different venous cannulation site** (Standard bicaval cannulation could dislodge the thrombus)