Quick Fire Cases
Mica Alex, MD
Cardiology Fellow
The Heart Hospital Baylor Plano
Mica Alex, MD
Cardiology Fellow
The Heart Hospital Baylor Plano
Rakushumimarika Harada, MD
Advanced heart failure cardiology fellow
Baylor Scott and White Heart Hospital in Plano
Rahul Sawhney, MD
Structural and Interventional Cardiology Fellow
The Heart Hospital Baylor Plano
Priyamvada Pillai, MD
Cardiology Fellow
The Heart Hospital Baylor Plano
Srinivasa Potluri, MD
Cardiac Structural and Interventionist
The Heart Hospital Baylor Plano
Nitin Kabra, MD
Advanced Heart Failure and Transplant Cardiologist
The Heart Hospital Baylor Plano
Zuyue Wang, MD
Advancing Cardiac Imaging Cardiologist
The Heart Hospital Baylor Plano
amro alsaid, MD
Cardiologist
Baylor Scott & White - The Heart Hospital Plano
A 41 year old male with a past medical history bicuspid aortic valve dysfunction, Ross procedure at age 22, pulmonic homograft endocarditis and severe pulmonic insufficiency status post transcatheter pulmonic valve replacement (26 mm Sapien Ultra) at age 38, and atrial fibrillation/flutter on Xarelto presented with worsening bilateral lower extremity edema, nausea, vomiting and significant weight loss after bariatric surgery.
Diagnostic Techniques and Their Most Important Findings:
A 4D CT heart was obtained to assess the prosthetic pulmonic valve. Incidentally, there was a homogenous and well-defined 12.8 mm hypoattenuated (mean Hounsfield Units of 44) mass noted. To further evaluate, a cardiac MRI was obtained and remonstrated a large mass laminating the right atrial free wall with no invasion or involvement of adjacent structures. In comparison with the myocardium, the mass was isointense to mildly hyperintense on T1 weighted black blood imaging and hyperintense on T2 weighted images. First pass perfusion showed low uptake of the mass (i.e. low vascularity). On delayed post Gadolinium imaging, homogenous diffuse mass enhancement was noted.
Learning Points from this Case:
On cardiac MRI, masses that are malignant tend to infiltrate surrounding structures, are heterogenous in appearance, and show high vascularity. These characteristics were not observed with this right atrial mass. T1 and T2 weighted imaging showed that the mass is hyperintense indicating that edema is present. Additionally, thrombus would not enhance on delayed post Gadolinium imaging. Based on these MRI findings, the differential diagnosis was narrowed down to fibroma or isolated atrial amyloidosis. A multidisciplinary team discussion led to the decision to perform a biopsy of the right atrial mass. Intracardiac echocardiography helped visualize the mass to safely perform endomyocardial biopsy. This patient was ultimately found to have biopsy-confirmed right atrial fibroma which is a benign tumor. This case highlights the complementary role of multimodality imaging and the utility of cardiac MRI sequences to provide a comprehensive characterization of cardiac masses in order to reach an accurate diagnosis.
