Key points
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Surgical removal is the mainstay of cardiac mass diagnosis and treatment.
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When complete tumor removal of the tumor is not possible or patient intention or condition does not allow proceeding toward the surgery, interventional radiology (IR) is a good option for the cardio-oncology team to consider.
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Interventional oncology (IO) is a rapidly developing branch of IR that encompass procedures to yield tissue sample for diagnosis, assist in treatment as neoadjuvant or palliation, and management of complications due to tumoral progression or treatment adverse effects.
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Accomplishment of the cardiac interventional procedures requires demanding skill, comprehensive knowledge, and specific preparation as well as appropriate setting (including available cardiac surgeon) for handling the occasional complications.
Interventional radiology (IR) is a specialized field, in which the physician not only interprets the medical images but also uses medical imaging to guide minimally invasive surgical procedures that diagnose, treat, and cure many kinds of conditions through small incisions in the body. The treatments IR can effectively perform are ever changing and expanding. Interventional Oncology (IO) is one of the fastest growing fields in interventional radiology, dedicated to the diagnosis, treatment, and palliation of cancer and cancer-related problems that had tremendous progress over the last decade, and has now successfully established as an essential and independent pillar within the firmament of multidisciplinary oncologic care. Cardiac mass interventions are one of the ignored interdisciplinary fields that have explored new encouraging horizons during past decade.
The appropriateness of minimally invasive interventions for any patient with cardiac tumor should be assessed individually by the multidisciplinary “cardio-oncology team.”
IR role in diagnosis
Minimally invasive diagnosis of the cardiac tumors can be performed either by percutaneous or endovascular approach obviating the need for open surgery.
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Percutaneous transthoracic biopsy of cardiac masses can be applied for pericardial, intramural, or even some cavitary lesions if trajectory access is appropriate. The procedure is mainly performed under CT scan or sometimes ultrasound guidance ( Fig. 29.1 ) while the backup cardiac surgeon is available and informed. Interventionists try to choose tumoral regions with the lowest amount of vascularity in order to diminish the possible risk of hemopericardium ( Fig. 29.2 ). Filling the intralesional biopsy tract at the end of procedure with embolizing agents (e.g., gelfoam) will largely reduce the incidence.
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Endovascular biopsy of the cardiac or central great vessel masses is a minimally invasive procedure that could be considered for right heart and septal tumor of adequate size in a manner commonly used for the blunt endomyocardial biopsy ( Figs. 29.3–29.6 ). Cases of transseptal approach of the left atrial mass are also reported . To guide the prompt site of target lesion for biopsy, concomitant echocardiography is crucial. TTE, although commonly used, gives less clear cardiac images than TEE, especially for the posterior wall mass and the patient with poor echo window, while the latter requires general anesthesia during the procedure. Intracardiac echocardiography (ICE) can provide better anatomical delineation of the lesion and targeting device without the need for general anesthesia, is more patient friendly, and will reduce radiation exposure for the echocardiographer during the procedure.