Multimodality Imaging for an LV mass: The Case of a 75-year-old Man Presenting with Dysphagia, Chest Pain and Presyncope (QF_FR_076)

Friday, January 31, 2025

8:30 AM – 8:40 AM East Coast USA Time

Location: Blue Room PreFunction - Kiosk 1

Presenting Author(s)

GS

Gabriela Spencer-Bonilla, MD, MSc

Fellow, Cardiovascular Medicine
Stanford University

Primary Author(s)

GS

Gabriela Spencer-Bonilla, MD, MSc

Fellow, Cardiovascular Medicine
Stanford University

Co-Author(s)

SB

Shire Beach, MD

Cardiology Fellow
Stanford University
Michael Salerno, MD, PhD

Cardiology Professor
Stanford University

Description of Clinical Presentation: A 75-year-old man with hypertension complicated by nephropathy requiring kidney transplant five years prior and one month of progressive dysphagia, post-prandial emesis, and 12-pound weight loss presented with chest pain, shortness of breath, and presyncope. Confluent white tongue plaques and raised ulcers in the oropharynx were noted on physical exam. Laboratory testing revealed elevated high sensitivity troponin (98 ng/L) and NT-proBNP (10,535 pg/mL) and acute kidney injury. An electrocardiogram (ECG) demonstrated sinus rhythm, inferior q-waves, diffuse T-wave inversions across the precordial leads, and multiple premature ventricular contractions.

Diagnostic Techniques and Their Most Important Findings: A transthoracic echocardiogram (TTE) with contrast was notable for normal left ventricle (LV) size, severe asymmetric hypertrophy of the interventricular septum, and a large apical LV mass (Fig. 1). A subsequent cardiac MRI (CMR) demonstrated an LV mass with ill-defined borders, measuring approximately 2.9 x 1.8 cm infiltrating the apical anterior and lateral walls. Tissue characterization (Fig 2) showed that the mass was (a) isointense on cine and (b) T1-weighted dark-blood (DB) images but was (c) hyperintense on T2-weighted DB images. The mass was (d) perfused and showed contrast enhancement on (e) post-contrast T1-weighted DB images and (f) late-gadolinium enhancement (LGE). There was a small rim of adherent thrombus present. CMR also demonstrated severe, asymmetric thickening of the basal septum with a maximum thickness of 19 mm in the anteroseptum with LGE of the inferior and anterior RV insertion sites consistent with hypertrophic cardiomyopathy (Fig. 3). Extracardiac findings were notable for a lower esophageal mass (4.1 x 2.7cm), hypoenhancing hepatic lesions, and multiple enhancing soft tissue masses in the chest wall suggestive of metastatic esophageal cancer (Fig. 3).

Learning Points from this Case: The most common left ventricular masses are thrombi, metastatic malignancies, fibroelastomas and sarcomas. This patient had the additional risk factor of solid organ transplant with immune suppression as well as the asymmetric left ventricular hypertrophy widening the differential diagnosis to include etiologies like post-transplant lymphoproliferative disorder and mass-variant hypertrophic cardiomyopathy. In this case, echocardiogram identified the mass, location and size, and demonstrated that it was perfused. CMR provided tissue characterization identifying the mass as likely a metastatic tumor with associated mural thrombus which was essential for expedited workup and treatment with systemic anticoagulation. CMR additionally identified the likely primary esophageal malignancy and extracardiac metastases. His case was complicated by thrombotic myocardial infarction. Esophageal biopsy identified the primary tumor as a moderately differentiated squamous cell carcinoma.