Quick Fire Cases
Orla Mc Carthy, MD
Fellow
Northwestern University
Orla Mc Carthy, MD
Fellow
Northwestern University
Orla Mc Carthy, MD
Fellow
Northwestern University
This case details a 38 year old female who initially presented in 2022 with shortness of breath and an elevated d-dimer. Her past medical history at that time was significant for uncomplicated celiac disease, and obesity. Following evaluation at an outside hospital, she was referred for CT pulmonary angiography to evaluate for pulmonary embolism. This demonstrated a 2.9 x 1.8cm mass in the left atrium, centred around the mitral valve, bilateral pleural effusions and pulmonary edema. While on the scanner, she developed acute respiratory failure requiring intubation and ventilation.
A trans-esophageal echocardiogram demonstrated severe functional mitral stenosis due to a 2.9 x 1.8cm mass on the posterior mitral valve leaflet with features suspicious for malignancy. She underwent a left atrial mass excision and metallic mitral valve replacement.
Post-operative pathology returned the rare diagnosis of a primary cardiac intimal sarcoma. A PET-CT outruled distant metastases, and other than post-surgical change, no uptake was seen at the site of tumor excision. Her post-operative course was complicated by severe pancytopenia and a symptomatic pericardial effusion. She recovered well post chemotherapy and was monitored regularly by the Hematology-Oncology service, and regular follow up CT chest abdomen and pelvis.
Diagnostic Techniques and Their Most Important Findings:
In May 2024, there was no radiological evidence of local or distant metastases. By early August 2024, an abnormality was noted on a follow up staging CT, which demonstrated a small mass-like lesion arising from the interatrial septum, which extended into the left atrium. The differential at this juncture was a neoplasm, versus thrombus.
A cardiac MR was performed which demonstrated near circumferential thickening of the posterior left atrium, with relative sparing of the fossa ovalis (Figure 1). The bulk of the mass is heterogeneously enhancing (Image 1), and centred at the interatrial septum, protruding into the left atrium, measuring 3.7 x 1.9 cm. Nodular thickening and enhancement does not extend to the ostia of the pulmonary veins. Left ventricular and right ventricular functional assessment was normal. A mitral valve replacement was observed, with moderate regurgitation by quantitative assessment.
Learning Points from this Case:
In summary, this is a rare case of a 38 year old female patient with a history of treated intimal sarcoma of the mitral valve, with CMR findings compatible with tumour recurrence almost two years post-operatively.
With the addition of CMR, the differentiation between a neoplasm versus left atrial thrombus could be discerned. Furthermore, the extent of left atrial involvement was more accurately assessed.
