Echocardiography and in particular TEE is well suited to assess for the presence of intracardiac masses such as thrombus or tumor. Other imaging modalities, especially cardiac MRI, play an important complimentary role in characterization of the masses (eg, differentiating thrombus from tumor). In this chapter, Dr. Grimm and his colleagues from the Cleveland Clinic will highlight the value of echocardiography in the evaluation of patients with intracardiac masses, including cases of primary and metastatic cardiac tumors and intracardiac thrombus.
SECTION 1: LEFT ATRIAL MYXOMA
CLINICAL CASE PRESENTATION
A 22-year-old woman who had been previously healthy, presented with acute right-sided paresthesias, expressive aphasia, and headache followed by weakness of all four extremities. The patient had an episode of tingling and numbness in the right lower extremity one month ago for which she did not seek medical care. The symptoms resolved spontaneously.
On physical examination she was hemodynamcially stable and had decreased motor strength in all four extremities. Cardiac exam revealed tachycardia without murmurs, gallops, or rubs. The initial CT scan of the head was negative; however, an MRI done later revealed acute infarcts in the territories of both middle cerebral and posterior inferior cerebellar arteries. An echocardiogram revealed depressed left ventricular systolic function (LVEF 25%) with wall motion abnormalities suggestive of Tako-tsubo cardiomyopathy, in addition to a left atrial (LA) mass attached to the fossa ovalis. Based on location, the echocardiographic appearance and the mobility of the left atrial mass, the presumptive diagnosis was an LA myxoma (Figures 9-1-1, 9-1-2, 9-1-3, 9-1-4, 9-1-5).
Parasternal long axis demonstrating a left atrial mass originating from the interatrial septum (arrow). RV = right ventricle, LV = left ventricle, LA = left atrium, MV = mitral valve, AV = aortic valve ▶ (see Video 9-1-1).
Video 9-1-1: Parasternal long axis demonstrating a left atrial mass originating from the inter-atrial septum.
TEE midesophageal 4 chamber view showing a left atrial mass with irregular surface originating from the interatrial septum (arrow). RV = right ventricle, LV = left ventricle, RA = right atrium, LA = left atrium ▶ (see Video 9-1-2).
Video 9-1-2: TEE mid-esophageal 4-chamber view showing a left atrial mass with irregular surface originating from the inter-atrial septum
TEE bicaval view showing a left atrial mass originating from the fossa ovalis (arrow). RA = right atrium, LA = left atrium ▶ (see Video 9-1-3).