Masses and tumors

Outline
• General
• Primary Cardiac tumors
– Benign
– Malignant
• Secondary Cardiac Tumors
– Benign
– Malignant
 General

• Neoplasia of the heart or pericardium is more

likely to be:

– Secondary, than
– Primary
Distribution, attachment sites, and types of intracardiac masses removed from 75
patients at Mayo Clinic Rochester from 1993 to 1998
 Relative incidence of tumors of the heart Type of Tumor No. %

• Benign • Malignant
• Myxoma 24.4% • Angiosarcoma 7.3%
• Lipoma 8.4% • Rhabdomyosarcoma 4.9%
• Papillary fibroelastoma 7.9% • Mesothelioma 3.6%
• Rhabdomyoma 6.8% • Fibrosarcoma 2.6%
• Fibroma 3.2% • Malignant lymphoma 1.3%
• Hemangioma 2.8% • Extraskeletal osteosarcoma
• Teratoma 2.6% • Neurogenic sarcoma
• Mesothelioma of atrioventricular • Malignant teratoma
node 2.3%
• Thymoma
• Granular cell tumor
• Leiomyosarcoma
• Neurofibroma
• Liposarcoma
• Lymphangioma
• Synovial sarcoma
• Pericardial cyst 15.4%
• Bronchogenic cyst 1.3%
An apical four-chamber view demonstrates a false tendon (arrows) in the left
ventricular (LV) apex. LA, left atrium; RA, right atrium; RV, right ventricle.
 Primary Cardiac Tumors

• Benign
– Myxoma
– Papillary fibroelastoma
– Fibroma
– Lipoma
– Rhabdomyomas
A: A myxoma (arrows) is seen in the left atrium (LA) on transesophageal imaging.
The mass is attached to the fossa ovalis. B: A four chamber view demonstrations a
large myxoma within the left atrium partially obstructs the mitral orifice during
diastole. LV, left ventricle; RA, right atrium; RV, right ventricle.
A: A myxoma (arrows) is seen in the left atrium (LA) on transesophageal imaging.
The mass is attached to the fossa ovalis. B: A four chamber view demonstrations a
large myxoma within the left atrium partially obstructs the mitral orifice during
diastole. LV, left ventricle; RA, right atrium; RV, right ventricle.
A large right atrial myxoma is indicated by the arrows. The mass extends through the
tricuspid valve into the right ventricle (RV). LA, left atrium; LV, left ventricle.
A, B: A papillary fibroelastoma of the mitral valve is
demonstrated. The tumor was attached by a small pedicle to
the anterior leaflet and was highly mobile. AV, aortic valve;
LA, left atrium; LV, left ventricle; RV, right ventricle.
A, B: A papillary fibroelastoma of the mitral valve is demonstrated.
The tumor was attached by a small pedicle to the anterior leaflet
and was highly mobile. AV, aortic valve; LA, left atrium; LV, left
ventricle; RV, right ventricle.
A. A small papillary fibroelastoma is
seen in a patient who had suffered a
stroke. The mass (arrow) is seen on
the posterior leaflet in diastole (A)
and systole (B). LA, left atrium; LV, left
ventricle.
An example of Lambl excrescence of the aortic valve is
demonstrated (arrows). Ao, aorta; LA, left atrium; LV, left
ventricle.

DD with fibroelastoma. Lambl excrescence are smaller

A. A blood cyst (arrow) within the
anterior mitral leaflet is shown.
The cyst is relatively immobile and
the attachment is broad based. The
mass is seen during diastole (A)
and systole (B). LA, left atrium; LV,
left ventricle; RV, right ventricle.
A. Lipomatous hypertrophy of the atrial septum is demonstrated.
A: A mild degree of accumulation of lipomatous material is present
(arrows). The fossa ovalis is characteristically spared. B: A more
extreme form of lipomatous hypertrophy is demonstrated
(arrows). LA, left atrium; LV, left ventricle; RA, right atrium; RV,
right ventricle.
A. Lipomatous hypertrophy of the atrial septum is demonstrated.
A: A mild degree of accumulation of lipomatous material is present
(arrows). The fossa ovalis is characteristically spared. B: A more
extreme form of lipomatous hypertrophy is demonstrated
(arrows). LA, left atrium; LV, left ventricle; RA, right atrium; RV,
right ventricle.
An example of endocardial fibroelastosis is shown. Endocardial
thickening in the left ventricular apex is present. Thrombus overlies
the thickened endocardium (arrows). LA, left atrium; LV, left ventricle;
RV, right ventricle.
unlike to fibromas the mass is endocardial rather than myocardium
A. A primary fibrosarcoma is demonstrated in the right heart.
A: The tumor involves the right ventricular outflow tract and
pulmonary artery. B: Narrowing of the right ventricular outflow
tract is indicated by the arrows. C: Doppler imaging
demonstrates an RVOT gradient of approximately 50 mm Hg.
LA, left atrium; RA, right atrium; RV, right ventricle; RVOT, right
ventricular outflow tract.
A, B: An example of angiosarcoma is provided. The mass had
infiltrated the lateral wall of the left atrium (LA) and left ventricle
(LV) and invaded the mitral valve. Obstruction to mitral inflow
was present. In real time, the heart appeared fixed due to
infiltration by the malignancy. A pericardial effusion is also
present. RA, right atrium; RV, right ventricle.
A, B: An example of angiosarcoma is provided. The mass had
infiltrated the lateral wall of the left atrium (LA) and left
ventricle (LV) and invaded the mitral valve. Obstruction to
mitral inflow was present. In real time, the heart appeared
fixed due to infiltration by the malignancy. A pericardial
effusion is also present. RA, right atrium; RV, right ventricle.
A. Metastatic
melanoma often
involves the heart.
A: Image quality
prevents
visualization of the
apical mass. B: After
contrast injection,
the outline of the
apical mass (arrows)
is apparent.
Metastatic melanoma involving the right ventricular
apex (arrows) is shown. LV, left ventricle; RV, right
ventricle.
A malignant pericardial effusion (asterisks) demonstrated in a
patient with bronchogenic carcinoma. LA, left atrium; LV, left
ventricle; RA, right atrium; RV, right ventricle.
A. Pericardial involvement of a mesothelioma is
demonstrated. A:A large mass (arrows) completely obscures
the right heart and encroaches on the left atrium (LA). B:
Subcostal image demonstrates the extent of the malignancy
(arrows) and the mass effect that it creates on the left
heart. LV, left ventricle.
A. Pericardial involvement of a mesothelioma is
demonstrated. B: Subcostal image demonstrates the
extent of the malignancy (arrows) and the mass effect
that it creates on the left heart. LV, left ventricle.
B: A lymphoma invading the heart and great vessels is shown. The tumor can be seen
encasing the aortic root and the posterior atrioventricular groove (arrows). After
successful chemotherapy, the echocardiogram appears essentially normal (C, D). LA,
left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle.
A. Renal cell carcinoma often affects the right heart. A: Tumors
fill the right atrium (arrows). This is the result of the extension
of the malignancy from the kidneys through the inferior vena
cava (IVC) (B). C: The tumor is seen invading the right ventricle.
Ao, aorta; LA, left atrium; LV, left ventricle.
A. Renal cell carcinoma often affects the right heart. A: Tumors
fill the right atrium (arrows). This is the result of the extension
of the malignancy from the kidneys through the inferior vena
cava (IVC) (B). C: The tumor is seen invading the right ventricle.
Ao, aorta; LA, left atrium; LV, left ventricle.
An example of carcinoid heart disease is shown. A: The right
heart is dilated and the tricuspid valve is thickened, fibrotic,
and immobile.
An example of carcinoid heart disease is
shown. The tricuspid leaflets are fixed
(B) and do not coapt in systole (C).
D: Color Doppler imaging demonstrates severe tricuspid
regurgitation. LA, left atrium; LV, left ventricle; RA, right atrium;
RV, right ventricle.
A large apical left ventricular thrombus is seen filling an apical
aneurysm. In real time, the thrombus demonstrated little
mobility. LA, left atrium; LV, left ventricle; RA, right atrium; RV,
right ventricle.
A. A small left ventricular apical thrombus (arrows) is recorded
from the apical two-chamber view (left). The thrombus
protrudes into the cavity and demonstrates mobility on real-
time imaging (right). LA, left atrium; LV, left ventricle.
B. A small left ventricular apical thrombus (arrows) is recorded
from the apical two-chamber view (left). The thrombus
protrudes into the cavity and demonstrates mobility on real-time
imaging (right). LA, left atrium; LV, left ventricle.
A. Standard apical four (A) and two-chamber (B) views,
respectively. From this window, the apex appears free of
thrombi. C, D: Off-axis imaging demonstrates a large, circular
mass (arrow) consistent with a thrombus. LV, left ventricle.
A. Standard apical four (A) and two-chamber (B) views,
respectively. From this window, the apex appears free of
thrombi. C, D: Off-axis imaging demonstrates a large, circular
mass (arrow) consistent with a thrombus. LV, left ventricle.
B. In patients with poor acoustic
windows, contrast injection can be
useful to outline a mural thrombus. A:
Without contrast, the thrombus is not
visualized. B: The presence of contrast
within the left ventricle (LV) outlines
the apical mass (arrows).
A. From a patient with severe heart failure due to dilated
cardiomyopathy, multiple thrombi are recorded. A: A left ventricular
apical thrombus and a large right atrial thrombus are indicated by the
arrows. B: A modified apical view demonstrates thrombi in both the
left and right ventricle (arrows). LA, left atrium; LV, left ventricle; RA,
right atrium; RV, right ventricle.
A. From a patient with severe heart failure due to dilated
cardiomyopathy, multiple thrombi are recorded. A: A left ventricular
apical thrombus and a large right atrial thrombus are indicated by the
arrows. B: A modified apical view demonstrates thrombi in both the
left and right ventricle (arrows). LA, left atrium; LV, left ventricle; RA,
right atrium; RV, right ventricle.
Endocardial thickening and fibrosis are characteristics of
hypereosinophilic syndrome. The highly echogenic mass
within the left ventricular apex is the result of this process. LA,
left atrium; LV, left ventricle; RA, right atrium; RV, right
ventricle.
An example of noncompaction of the left ventricular myocardium
is illustrated. Systolic (A) and diastolic (B) images are provided.
The left ventricle (LV) apex has a thickened, spongiform
appearance (arrows).
A. An echogenic, small apical mass (arrow) is
recorded in a patient with normal left ventricular wall
motion. The two-chamber view is shown in diastole
(A) and systole (B). This likely represents a
trabeculation or muscle bundle within the cavity. LA,
left atrium, LV, left ventricle.
In a patient with untreated rheumatic heart disease, a very large
left atrial thrombus (arrows) is seen. The right atrium (RA) is also
severely dilated. LV, left ventricle; RV, right ventricle.
A. The left atrial appendage (asterisk) sometimes can be
recorded using transthoracic echocardiography from the apical
two-chamber view (A). B: A thrombus within the appendage is
indicated by the arrow. LA, left atrium; LV, left ventricle.
A. Transesophageal echocardiography is
used to assess the left atrial appendage
for thrombus. A: A normal left atrial
appendage is demonstrated.
A. Transesophageal echocardiography is
used to assess the left atrial appendage
for thrombus. B: The arrows indicate
small pectinate muscles within the
appendage. These are normal structures
that are sometimes confused with
thrombi.
A. Transesophageal echocardiography is
used to assess the left atrial appendage
for thrombus. C: A multilobed
appendage is illustrated, the different
lobes indicated by the arrows. LA, left
atrium; LV, left ventricle.
A. Two examples of left atrial
appendage thrombi are included. A: A
relatively small, nonmobile thrombus is
indicated by the arrows. B: A larger
thrombus is present (arrows) and
appears to fill most of the appendage.
Ao, aorta; LA, left atrium.
An example of a small thrombus within the left atrial appendage
is demonstrated. LA, left atrium.
A: A left atrial appendage (LAA) thrombus (arrow) is recorded
with two-dimensional imaging. B: Pulsed Doppler imaging
records low (<20 cm/sec) atrial appendage emptying velocity.
Spontaneous echo contrast was also present within the left
atrium
A, B: A thrombus is recorded straddling the
interatrial septum through a patent foramen ovale
and extending into the left atrium (small arrows).
The thrombus was highly mobile and likely
originated in the lower extremities. Increased
mobility of atrial septal tissue is indicated by the
large arrow LV, left ventricle; RA, right atrium; RV,
right ventricle.
A large, tubular-shaped thrombus (arrows) is demonstrated as it crosses a patent
foramen ovale. The shape of the thrombus suggests that it was formed within the
veins of the lower extremities. Its presence within the left heart greatly increases
the likelihood of systemic embolization. The four images were recorded over
several minutes, demonstrating the thrombus in the left and right atrium, and
straddling the patent foramen ovale (lower right panel). Ao, aorta; LA, left atrium;
RA, right atrium.
A large, tubular-shaped thrombus (arrows) is demonstrated as it crosses a patent
foramen ovale. The shape of the thrombus suggests that it was formed within the
veins of the lower extremities. Its presence within the left heart greatly increases
the likelihood of systemic embolization. The four images were recorded over
several minutes, demonstrating the thrombus in the left and right atrium, and
straddling the patent foramen ovale (lower right panel). Ao, aorta; LA, left atrium;
RA, right atrium.
A large, tubular-shaped thrombus (arrows) is demonstrated as it crosses a
patent foramen ovale. The shape of the thrombus suggests that it was formed
within the veins of the lower extremities. Its presence within the left heart
greatly increases the likelihood of systemic embolization. The four images
were recorded over several minutes, demonstrating the thrombus in the left
and right atrium, and straddling the patent foramen ovale (lower right panel).
Ao, aorta; LA, left atrium; RA, right atrium.
A large, tubular-shaped thrombus (arrows) is demonstrated as it crosses
a patent foramen ovale. The shape of the thrombus suggests that it was
formed within the veins of the lower extremities. Its presence within the
left heart greatly increases the likelihood of systemic embolization. The
four images were recorded over several minutes, demonstrating the
thrombus in the left and right atrium, and straddling the patent foramen
ovale (lower right panel). Ao, aorta; LA, left atrium; RA, right atrium.
A. Thrombi can occasionally be recorded during transit
through the right heart. A---D: Small thrombi are recorded at
various locations within the right atrium and right ventricle
(RV) (arrows). These will most likely lead to a pulmonary
embolism. LA, left atrium; LV, left ventricle.
A. Thrombi can occasionally be
recorded during transit through
the right heart. A---D: Small
thrombi are recorded at various
locations within the right atrium
and right ventricle (RV) (arrows).
These will most likely lead to a
pulmonary embolism. LA, left
atrium; LV, left ventricle.
The bicaval view is useful to interrogate indwelling catheters
and pacemaker leads for the presence of thrombi and/or
vegetations. In this example, a pacemaker lead extends from
the superior vena cava into the right atrium (RA) (small
arrows). A mass within the lower portion of the right atrium
(large arrow) represents thrombus attached to the lead. LA,
left atrium.
This apical four-chamber view from a patient with dilated
cardiomyopathy demonstrates spontaneous echo contrast
within the left ventricle (LV). This is due to low blood flow. LA,
left atrium; RA, right atrium; RV, right ventricle.
Complex aortic atheroma (arrows) is demonstrated using
transesophageal echocardiography. The walls of the aorta are
thickened and a mobile atheroma is present.
Detecting the presence of a patent foramen ovale often relies on
color flow imaging. In this example, a small degree of shunting
between the right (RA) and left atrium (LA) is present.
More extensive shunting is present in this example and is
demonstrated using injection of agitated saline through a
peripheral vein. The interatrial septum shows excessive mobility,
and a clear tunnel-like defect is present. The degree of shunting
can be estimated by virtue of the number of bubbles that
appear within the left atrium (LA). Ao, aorta.
An example of an atrial septal aneurysm is shown.
A: The aneurysm billows into the left atrium (LA)
(arrows). B: The redundant tissue billows into the
right atrium (large arrow). Injection of contrast
into the right heart confirms an associated patent
foramen ovale by demonstrating right-to-left
shunting. LV, left ventricle; RV, right ventricle.
An example of a hiatal hernia is provided. A: An echo-free space
behind the left heart (arrows) is noted. B: The short-axis view
confirms that the structure is below the diaphragm. C: The patient
is given a carbonated beverage to drink. This produces a contrast
effect within the structure, confirming that it is hiatal hernia. Ao,
aorta; LV, left ventricle; RV, right ventricle; RA, right atrium.
An example of a hiatal hernia is provided. A: An echo-free space
behind the left heart (arrows) is noted. B: The short-axis view
confirms that the structure is below the diaphragm. C: The patient is
given a carbonated beverage to drink. This produces a contrast effect
within the structure, confirming that it is hiatal hernia. Ao, aorta; LV,
left ventricle; RV, right ventricle; RA, right atrium.
These transesophageal images were recorded from a patient 2 days after
coronary artery bypass surgery. A systolic (left) and diastolic (right) image are
provided. The patient had become hypotensive. A large, amorphous mass
within the pericardial space can be seen to impinge on the right atrium (RA)
and right ventricle (RV). This represents a hematoma that compressed the
right heart and contributed to the hypotension. LA, left atrium; LV, left
ventricle.
A large pericardial cyst (arrows) is demonstrated from the
apical four-chamber view. These cysts are typically circular, thin
walled, and echo free. They are often located near the right
costophrenic angle. LA, left atrium; RA, right atrium; LV, left
ventricle; RV, right ventricle.