Missiles, Masses, and Myxomas

Covers etiology, pathophysiology, physical signs, echo appearance, m-mode/Doppler findings, and Q & A from PowerPoint lecture DSAE 2404.

Causes of missiles (foreign body in the heart)

iatrogenic
bullets
knives
nails
ice pics

iatrogenic

healthcare provider induced

physical signs of missiles

bleeding — entrance & possible exit wound
murmur
tamponade physiology (clinical presentation i.e. Beck’s triad)

pathophysiology (consequences of missiles)

myocardial rupture
ASD and/or VSD
valvular disruption
pericardial effusion
coronary artery trauma

What percent of patients with a missile penetrating the heart will not have a pericardial effusion?

25-50%

echo appearance of missiles

look for echogenic structures with strong reverberation
pericardial effusion not always present
disrupted valve leaflets / support apparatus (regurgitation)
ASD/VSD may be visualized if large enough
WMAs from CA trauma
always perform a bubble study (microcavitation study)

Doppler findings of missiles

intracardiac shunt may be present — which direction is it flowing
evaluate regurgitation
ASD/VSD may show turbulent flow
transvalvular respiratory flow variations when tamponade physiology is present

bullet / pellet wounds

x-rays for reference, use off-axis views

What part of the heart is most likely to be affected by cardiac contusion?

right ventricle

causes of cardiac masses

thrombus formation
benign tumors
malignant tumors

types of malignant tumors in the heart

primary (20%) — starts in the heart
metastatic (most common) — spreads to the heart

physical signs of cardiac masses

heart murmurs due to stenosis or regurgitation

What is the most common type of benign intracardiac tumor in adults?

myxomas

thrombus formation in the heart

may form in areas of akinesis or dyskinesis
most commonly found at ventricular apex
LA thrombi usually associated with MS and LAE

papillary fibroelastoma

most common benign cardiac valve tumor

characteristics of papillary fibroelastoma

mostly found on AoV and MV
TV most commonly affected in pediatric cases
may be single or multiple
tumors have been noted on chordae tendonae of MV
usually asymptomatic and incidental finding but can embolize
may mimic vegetation

Rhabdomyoma

most common benign intracardiac tumor in children

most common metastatic tumors that spread to the heart

sarcoma, melanoma, lymphoma of breast or lung

What percent of primary cardiac tumors are malignant?

20%

Echo appearance (thrombus)

may be layered, pedunculated, multilobulated, or single
appears as an echogenic mass in areas of akinesis or dyskinesis
search ventricular apex closely with high frequency
visualize the mass at different depths from 2 or more views
RT sided masses can be delineated with UEA

Angiosarcoma

most common primary malignant tumor, most often seen in RA

Doppler findings of cardiac masses

valvular stenosis and/or regurgitation may occur with obstructive masses

What might be the first indication of metastatic cardiac disease?

pericardial effusion

Which cardiac chamber is most likely involved with metastatic tumors?

right atrium

The most common benign tumor on the aortic valve is:

papillary fibroelastoma

causes of myxomas

benign tumors (50%, most common benign cardiac tumors in adults)

consequences of myxomas

over 75% of myxomas are in LA, can appear in RA
LA myxomas may mimic mitral stenosis

physical signs of myxomas

malaise / unwell
dyspnea
murmur of MS w/ tumor “plop” is classic (50% of the time)
embolic phenomena (35% of the time)
CP (rare)

Echo / Doppler appearance of myxomas

atrial myxomas usually attach to the IAS by a stalk (pedunculated)
intracavitary tumors will usually move with blood flow
Doppler: stenosis and regurgitation may be present with obstructive LA masses

intramyocardial tumors

usually have borders or texture that is different from myocardium

A patient with a left atrial myxoma may have symptoms similar to patients having:

mitral stenosis

Where are most fibroelastomas found?

usually on the MV and AoV

A patient has a “frond-like” or feathery mass on the AoV. What is the most likely diagnosis?

fibroelastoma

Pediatric patients with tuberous sclerosis develop what type of cardiac tumors?

rhabdomyomas

What is the most common type of pediatric cardiac tumor?

rhabdomyoma

Which of the following best describes papillary fibroelastomas?

valvular tumor that is usually attached to the surface of the aortic or mitral valve leaflets in adults

lipoma

benign, fatty tumor
circumscribed, encapsulated, usually solitary
most common in LV, RA, or IAS
surgical excision may be necessary

lipomatous hypertrophy of the interatrial septum

thickened IAS, dumbbell appearance with sparing of the fossa ovalis

fibroma

usually ventricular and solitary
most commonly found in myocardium of LV, RV, or IVS
heart transplant may be necessary for children with a very large LV fibroma

2nd most common benign tumor in pediatric patients

fibroma

sarcoma

most common primary cardiac malignant tumor

angiosarcoma

most common sarcoma, usually located in the RA, 80% metastasize

rhabdomyosarcoma

2nd most common cardiac sarcoma

IVC tumors

nephroblastoma (most common, Wilk’s tumor)
leiomyosarcoma
renal cell carcinoma

vegetation vs. fibroelastoma

vegetation: present on flow side of valves; clinical presentation of infective endocarditis (fever, chills, etc.); cause valvular dysfunction

fibroelastoma: can form on downstream side of valves, rarely cause valvular dysfunction, usually asymptomatic or non-infected symptoms

Lambl’s excrescence vs. fibroelastoma

Lambl’s excrescence: only affects the aortic valve

fibroelastoma: affects MV, MV chordae tendonae, AoV, and TV (in children)