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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Mass in the LVOT
Case#: 39
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
Presentation:
75 y.o. male with a history of HTN, COPD, Colon and Prostate Cancer who is on Zocor, ASA, and Metoprolol.
A pre-chemotherapy echocardiogram was abnormal. A cardiac cath showed no coronary artery disease.

Please review the TEE and give your assessment.
Questions to consider are:

What is the differental diagnosis?
Do colon or prostate cancer metastasize to the heart?
Can trauma from the AR jet cause this condition?
What is the recommended therapy?
 
Loops:


Case Discussion/CME Questions
 
The TEE showed a mass in the LVOT that appeared to be attached to the anterior mitral valve.
Specifically, the mass appeared to be attached near A3.
The LVEF was 50%.
The wall motion was normal.
There was mild aortic insufficiency.
There was minimal turbulence in the LVOT.
The AR jet appeared to be directed towards the mass.
The aortic valve had Lambl's Excressences



Tumors of the heart are separated into different classifications:

Benign
Malignant

Benign tumors occur in 80% of the tumors of the heart and are:

Myxoma     27%
Lipoma  10%
Papillary Fibroelastoma 10%
Hemangioma 3%
Mesothelioma of the AV Node 1%

Cysts can also occur in the following incidence:

Pericardial Cyst 18%
Bronchogenic Cyst 2%

The most common benign tumor is a myxoma. Myxomas typically occur upstream side of the valve.
Myxomas can be large, have a ground-glass consistency, are irregular, mobile, have a stalk (some are very long or very short), and are pliable.
Myxomas can exhibit emboli phenomena or cause obstructive symptoms (syncope).

Myxoma Locations:
LA 75%
RA 18%
LV 4%
RV 4%
Multiple 5%

Myxomas can also be part of the Carney Complex:

Mutiple lentigines and blue nevi
Peripheral myxoid tumors
Psamommatous melanotic schwannoma
Endocrine over activity
    Cushingâ‚Ǩ‚Ñ¢s Syndrome
    Pituitary Adenomas
    Testicular Sertoli cell tumors
Multiple Recurrent Cardiac Masses   

The Carney Complex is familial/autosomal dominant.


 

Fibroelastomas are the second most common tumor and typically occurs on the downstream side of a valve. Fibroelastomas arise from valvular
tissue and are histologically similar to Lambl's Excressence. Fibroelastomas are usually small, and mobile. A fibroelastoma usually appears as a 
cauliflower or frond-like tumor. On echocardiography it appears to be similar to a sea anemone. Fibroelastomas can have pieces break off and embolize or 
the whole tumor can embolize. Fibroelastomas can be confused with vegetations. Vegetations are usually on the upstream side of a valve.

Lipomatous hypertrophy of the atrial septum can occur. Usually the superior and inferior portions of the septum have lipomatous deposition and
the fossa ovalis is spared making the atrial septum appear as a bow-tie. Occasionally the fossa ovalis exhibits rings of limpoatous depostions.

Malignant tumors of the heart comprise 20% of the cardiac tumors. Local invasion or metastastic tumors are:

Lung
Liver
Breast
Leukemia
Stomach
Melanoma
Lymphoma (AIDS)
Colon

Primary cardiac malignancies are:

Angiosarcoma 9%
Rhabdomyosarcoma 5%
Mesothelioma 4%
Fibrosarcoma 3%
Malignant Lymphoma 2%
Extraskeletal Osteosarcoma 1%

Other tumors invade the heart via the venous system are are:

Renal Cell Carcinoma
Uterine Leiomyosarcoma

Lastly, tumors can affect the heart by production of neuroendocrine substances such as:

Carcinoid Tumors
Pheochromocytoma

For this case, while the pathology came back as a fibroelastoma the intraoperative image if the tumor did not have the typical
fond-like appearance of a fibroelastoma.

Refs:
Braunwald's Heat Disease
Clinical Echocardiography


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