The Role of Echocardiography in the Management of the Sources of Embolism

Roberta Esposito; Rosa Raia; Daniela De Palma; Ciro Santoro; Maurizio Galderisi

Disclosures

Future Cardiol. 2012;8(1):101-114. 

In This Article

Cardiac Tumors

Cardiac tumors range from benign lesions to high-grade malignancies and occur over a wide range of ages.[34] Approximately 90% of primary cardiac tumors are either myxomas or sarcomas. Echocardiography is the first choice for diagnosis of cardiac tumors among imaging modalities.[35]

Primitive Cardiac Tumors

Primitive cardiac tumors are rare, with autoptic incidence varying between 0.001–0.33%. Approximately 75% of primitive tumors are benign (Table 2).[36–38]

Benign Tumors

Myxomas Myxoma is the most frequent cardiac tumor (30–50% of cases), more frequent in the adults and in women (70%). It is responsible for 11% of youthful stroke and of thrombo-embolic events (32–33%).[36–38] Myxoma may be symptomatic (arthralgia, rash, fever, weight loss and fatigue) but it is very often completely asymptomatic for years and years. The most frequent location of myxoma the is left atrium (75–85%) at the level of oval fossa (Figure 7), followed by the right atrium, the ventricles and the mitral valve, while tricuspid localization is very rare. In ≥90% of cases it is single but 5% shows biatrial localization. Myxoma recidivism after surgery occurs in 5–14% of the cases.[1] TTE is the elective tool for diagnosis but TEE permits to identify more precisely characteristics, size, relations with neighboring structures.[39] Myxoma shows a certain individual variable consistency even if it is very often homogenous, with a globular or gelatinous aspect. Its surface is regular or irregular, sometimes the size is large such to occupy almost all the atrial cavity; anechogenic spaces with inhomogeneous reflectivity corresponds to hemorrage or necrosis in its context. Cardiac MRI can be sometimes useful to define the tumor's margins and to exclude infiltration.[40]

Figure 7.

Transthoracic echocardiogram evidence of cardiac myxoma.
The presence of an oval, homogeneous formation is detectable in both apical four chamber view, (A) either in harmonic or by using (C) color Doppler and (D) in subcostal four chamber view. (B) This is a left atrial myxoma localized at the atrial septum, in correspondence of the fossa ovalis.

Papillary Fibroelastomas Fibroelastomas are the most common valve-associated tumors (>85–90% of them), have high embolic capacity and can determine mechanical valvular dysfunction.[5] They are small (≤1 cm), have a gelatinous consistency (multiple papillary foliage), are often linked to the endocardium by a short peduncle, very frequently originate from valvular endocardium, thus being often confused with vegetations. They are localized on mitral and aortic valves in individuals >60 years, while they are more common on tricuspid valves in childhood.[36]

Other Benign Tumors Lypomas and rhabdomyomas (the most frequent primitive cardiac tumors in pediatrics, in particular in the first year of life), very often localized at the level of interventricular septum, present low embolic capacity.

Malignant Tumors Primitive malignant cardiac tumors represent 25% of cardiac tumors and include almost exclusively sarcoma (approximately 90%). Despite their heterogeneous origin, they present rapid proliferation and provoke severe damage of cardiac structures. They have rapid clinical course and evil prognosis regardless of treatment. Differential diagnosis by metastatic masses is needed.

Secondary Cardiac Tumors

Metastatic cardiac tumors are 20–40-fold more common than primitive cardiac tumors.[36] Pulmonary carcinoma and breast carcinoma often involve the heart for direct invasion (contiguity). Other tumors can reach the heart for lymphatic invasion. Among these, melanomas (cardiac metastasis in 64% of cases), leukemia and lymphoma (>46% of cases) are often involved.

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