Intra-cardiac Masses and Devices

Intra-cardiac Masses and Devices

Al Solina, F. Luke Aldo and Salvatore Zisa

Cardiac Masses: A mass by any other name, is still a mass. Or is it?

You may remember from high school physics that mass is simply a quantity of matter. Under the right set of circumstances, it can even be converted into a predictable amount of energy. But that’s not what we are talking about here. Cardiac masses come in a variety of shapes, sizes, locations, consistencies, and clinical significance. They can be characterized primarily into real masses, and normal anatomical structures that masquerade as masses. Real cardiac masses can be further characterized as being benign or malignant, and as being primary or metastatic. In order to differentiate between these possibilities it is important to understand normal anatomy, the physics involved with imaging artifacts (see Chapter 5), and the characterization of real cardiac masses. Echocardiography has been utilized to image cardiac masses since the 1950s, and can be used to characterize the anatomy and pathophysiological consequences of the mass. Although a mass may be histologically benign, it may muck up the normal function of the heart by interfering with chamber filling or valve function, and therefore not be benign from a physiological perspective.

Masses that are Not Really Masses

Normal anatomic variants: these structures, although normal anatomic features, may mimic cardiac masses.

Atrial Anatomic Variants

Chiari network—having little to do with communications or information technology, this network is a filamentous embryological remnant located in the RA.

Coumadin ridge—a finger-like projection of tissue in the LA, which separates the left superior pulmonary vein from the left atrial appendage. It is sometimes mistaken for a thrombus.

Crista terminalis—not a train station in Rome, but rather a ridge of tissue in the RA located at the junction of the SVC and the RA appendage.

Eustachian valve—an embryological remnant, located at the junction between the IVC and the RA, and directed towards the fossa ovalis of the interatrial septum.

Foreign bodies—pacemaker and AICD leads, catheters, and cannulae of all different flavors may parade around in the atria. Additionally they may cause reverberations and side lobe artifacts that further muddle things up.

Lipomatous hypertrophy of the interatrial septum—this benign variant is characterized by a sometimes dramatic thickening of adipose tissue surrounding, but sparing the fossa ovalis of the interatrial septum. It kind of looks like a dumbbell. Thick-thin-thick. While not having any meaningful significance in terms of acute pathophysiological consequence, it is easy to recognize and very impressive to say.

Pectinate muscles—line the RA in a perpendicular array.

Ventricular Anatomic Variants

False chords—nothing false about them. They are real anatomic structures. They are typically thin, well…chords running across the LV, near the apex.

Foreign bodies—as above.

Papillary muscles—hard to confuse these for anything abnormal if you know their standard anatomical location, and the fact that they have the appearance of myocardium. These muscles are found anterolaterally and posteromedially in the LV, and attach to the mitral valve via the chordae tendinae.

Trabeculations—muscular ridges, which can be quite prominent, especially in the RV.

Moderator band—this is not some politically correct hip-hop band, it’s a muscular band of tissue that traverses the apical third of the RV. It can be confused with a thrombus or tumor.

Valvular Anatomic Variants

Nodules of Arantius—small nodules along the coaptation point of the aortic valve.

Lambl’s excrescences—filamentous structure on the systemic side of the aortic valve, originating near the coaptation point.

Artifacts may appear for all the world to be true cardiac masses. It is important to interrogate a suspected mass in different views to ascertain its true anatomical nature. Artifacts tend to disappear with alternate imaging planes. Be suspicious when you see a structure crossing normal anatomic boundaries, this is another indication that you may be looking at an artifact.

Masses that Really are Masses

“Benign” primary cardiac masses: these masses are “benign” in their tissue characterization, but may misbehave and cause functional disturbances attributable to their anatomical location!

Myxoma—most common primary tumor, seen most frequently in the LA. Can be quite large and interfere with valvular function. Have a non-homogeneous appearance. Female preponderance. May commonly be seen attached to a stalk from the LA side of the interatrial septum. May be associated with systemic embolization.

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Jun 4, 2016 | Posted by admin in CARDIOLOGY | Comments Off

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