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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 13  |  Issue : 1  |  Page : 46-50

Cardiac masses diagnosed on transthoracic echocardiography at Nigerian Tertiary Hospital: A 3-year review


Department of Internal Medicine, Division of Cardiology, University of Maiduguri Teaching Hospital, PMB 1414, Maiduguri, Nigeria

Date of Web Publication13-Jan-2016

Correspondence Address:
Mohammed Abdullahi Talle
Department of Internal Medicine, Division of Cardiology, University of Maiduguri Teaching Hospital, PMB 1414, Maiduguri
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-7969.165164

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  Abstract 

Background: Echocardiography has since its inception, assumed a significant role in evaluation of cardiac masses, supplanting other diagnostic modalities for this purpose. We reviewed the various kinds of cardiac masses detected using transthoracic echocardiography in our center over a period of 3-year.
Materials and Methods: Echocardiographic data of patients that underwent transthoracic echocardiography from January 2011 to December 2013 were retrieved. All subjects had standard transthoracic echocardiography including all forms of Doppler modalities where appropriate. Descriptive statistics was used in assessing the proportion of the different cardiac masses observed.
Results: One thousand three hundred and two transthoracic echocardiograms were performed over the 3-year period, out of which 1224 comprising 591 (48.3%) males and 633 (51.7%) females were retrieved and reviewed. Their mean age was 39.62 (20.6) years. Cardiac masses were documented in 106 (8.7%) of the subjects. The most common cardiac mass was intracardiac thrombus, observed in 89 (84.0%) followed by vegetation in 10 (9.4%). A presumptive diagnosis of right atrial myxoma was made in 4 (3.8%), whereas 1 (0.9%) had a right atrial mass of uncertain cause. Inferior vena cava mass and metastatic lesion to pericardium were each diagnosed in 1 (0.9%) patient. Most of the cardiac thrombi involved the left ventricle (94.4%), whereas vegetations were mainly on the mitral valve (80%).
Conclusion: The dominant causes of cardiac mass observed are cardiac thrombus, commonly involving the left ventricle, and vegetations on mitral valve.

Keywords: Cardiac masses, echocardiography, myxoma, thrombus, vegetation


How to cite this article:
Talle MA, Anjorin CO, Buba F, Bakki B. Cardiac masses diagnosed on transthoracic echocardiography at Nigerian Tertiary Hospital: A 3-year review. Nig J Cardiol 2016;13:46-50

How to cite this URL:
Talle MA, Anjorin CO, Buba F, Bakki B. Cardiac masses diagnosed on transthoracic echocardiography at Nigerian Tertiary Hospital: A 3-year review. Nig J Cardiol [serial online] 2016 [cited 2019 Sep 21];13:46-50. Available from: http://www.nigjcardiol.org/text.asp?2016/13/1/46/165164


  Introduction Top


The primary imaging technique for the diagnosis of cardiac masses is the two-dimensional echocardiography.[1] The initial task of evaluation involves differentiating actual cardiac masses from artefacts due to electrical interference, characteristics of ultrasound transducers or physical factors such as beam artefacts, near-field artefacts, and multipath artefacts. Abnormal structures presenting as masses within or around the heart includes thrombi, tumors, and vegetations.[2] Differentiating cardiac masses from potential mimickers can be quite challenging. Structures other than the artefacts, that could be mistaken for a cardiac mass includes the moderator band,  Eustachian valve More Details, chiari network, trabeculations, pectinate muscles, surgical sutures, pacemaker leads, cardiac catheters, as well as ultrasound artefacts. Cardiac masses can be differentiated from artefacts by appropriate transducer selection, improved scanning technique, and use of multiple scanning windows including off-axis imaging.[1]

Two-dimensional echocardiography have evolved over the years, becoming the primary imaging technique for evaluation of cardiac masses with a sensitivity of 93% and 97% for transthoracic and transesophageal echocardiography, respectively.[3] Because of its advantages of cost effectiveness, noninvasive nature and high spatial and temporal resolution, transthoracic echocardiography remains the first choice modality. Transesophageal echocardiography is reserved for suboptimal images or posteriorly located cardiac masses in the left atrium and mitral valve.[1]

In addition to visualization of cardiac masses, echocardiography has the advantages of evaluating their anatomic nature as well as the hemodynamic consequences. It also provides additional information regarding the substrates for the development of vegetation (e.g., valvular heart diseases) and thrombi (e.g., regional wall motion abnormality, cardiac aneurysm, and systolic function).[2] Additional imaging modalities for evaluation of cardiac masses include cardiac computed tomography (CT), cardiac magnetic resonance imaging, and angiography.

The most common masses visualized within the heart are thrombus and vegetations associated with infective endocarditis.[1] Thrombus commonly complicates acute myocardial infarction, chronic dilated cardiomyopathy (DCM), and chronic left ventricular aneurysm.[4] For tumors, secondary metastases are by far the most common, resulting from cancers of the lungs, breast, thyroid, lymphomas, and melanomas.[5] The most common primary tumor of the heart is atrial myxoma, accounting for as much as 50% of cases.[6] Atrial myxoma occurs in the left atrium in 75% of cases, and the right atrium in 25% of cases. Available Nigerian studies showed varying prevalence rate for cardiac masses, ranging from 0.12% to 1.3%.[7],[8],[9],[10],[11] We had previously reported a high burden of left ventricular thrombus (LVT) among patients with abnormal echocardiograms in our center with a prevalence of 8.9%.[12]

We present a review of all cardiac masses detected on echocardiography in our center over a 3-year period.


  Materials and Methods Top


We studied the echocardiographic data of patients that underwent transthoracic echocardiography at our hospital over a 3-year period from January 2011 to December 2013.

Echocardiograms were obtained using MyLab 50CV (Esaote) and Siemens Acuson X300 (Siemens) ultrasound machines adhering to the American Society of Echocardiography guideline.[13] Where necessary, off-axis views were obtained to optimize visualization of intracardiac masses. Imaging was performed by trained cardiologists with expertise in echocardiography. All images are routinely copied from the hard drive of the ultrasound machine to a CD/DVD for storage. All images archived over the period under review were retrieved and reviewed.

Cardiac masses were identified as structures distinct from the heart, maintaining the same anatomic location throughout the cardiac cycle when visualized from more than one acoustic window [2] Vegetation was identified as irregularly shaped mass with discrete echogenicity that may or may not exhibit independent motion from the structures to which it is attached, visualized from multiple acoustic windows.[1] Diagnoses of the various cardiac conditions were made based on existing standard guidelines, as indicated in our previous publication.[12] The data was analyzed using SPSS version 16.0 Chicago, IL, USA. Descriptive statistics was used in determining the proportion of the different cardiac masses identified. Approval for this study was granted by the Research and Ethics Committee as part of the Heart Failure Registry.


  Results Top


One thousand three hundred and two transthoracic echocardiograms performed over the 3-year period, out of which 1224 comprising 591 (48.3%) males and 633 (51.7%) females were retrieved and reviewed. The mean age was 39.62 (20.6) years. All cases of cardiac masses were documented in the adult population.

Cardiac masses were documented in 106 (8.7%) of the subjects. The different types and locations of cardiac masses are illustrated in [Table 1]. The most common cardiac mass was intracardiac thrombus, observed in 89 (84.0%) of subjects, with 84 (94.4%) involving the left ventricle. Eleven (13.1%) of those with LVT had coexisting right ventricular thrombus, while 2 (2.4%) had an associated left atrial thrombus. Isolated right ventricular thrombus was observed in 2 (0.2%), whereas isolated left atrial thrombus was seen in 3 (0.3%) subjects with rheumatic mitral stenosis. A thrombus was also visualized in the pulmonary trunk of one of the subjects with right ventricular thrombus.
Table 1: Types and locations of cardiac masses

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The most common echocardiographic diagnoses associated with intracardiac thrombus were DCM (37.1%), ischemic cardiomyopathy (28.1%), and peripartum cardiomyopathy (PPCM) (20.2%). The various locations of intracardiac thrombus are illustrated in [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d.
Figure 1: (a) Massive apical thrombus in the left ventricle (white arrow) sealing off a pseudoaneurysm complicating extensive myocardial infarction. (b) Mass in the right atrium (arrow), suspected to be a thrombus. (c) Subcostal view showing a well-circumscribed right ventricular thrombus (arrow). (d) Parasternal short axis view showing a thrombus (arrow) in the left atrial appendage

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Vegetation was observed in 10 (9.4%), with the majority (80.0%) being in patients with rheumatic heart disease, and remaining 2 (20.0%) in patients with mitral valve prolapse. The mitral valve was commonly involved (80.0%), followed by the aortic valve (20.0%) [Figure 2]a. Vegetation was also observed on the tricuspid valve of one the subjects with mitral valve involvement.
Figure 2: (a) Vegetation (arrow) attached to the ventricular side of aortic valve in a patient with rheumatic heart disease. (b) Right atrial myxoma with attachment to interatrial septum. (c) Right atrial myxoma seen prolapsing into the tricuspid valve in (arrow). (d) A mass (arrow) attached to the inferior vena cava at its junction with the right atrium

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A presumed atrial myxoma was diagnosed in 4 (3.8%) subjects, with all involving the right atrium [Figure 2]b and [Figure 2]c, while a right atrial mass of uncertain etiology was visualized in 1 (0.9%) subject [Figure 1]b. A mass was visualized attached to the inferior vena cava (IVC) at its junction with the right atrium 3 months following the excision of a right atrial myxoma [Figure 2]d. The extension of the IVC mass outside the heart was difficult to be established.

Metastases to the pericardium from a hepatocellular carcinoma were diagnosed in 1 (0.9%) patient.


  Discussion Top


We report a prevalence of 8.7% for various kinds of cardiac masses among patients that had transthoracic echocardiography over a 3-year period at a Tertiary Hospital in North-Eastern Nigeria. This is the first report on the types and etiology of cardiac masses from the region. The overall prevalence is higher than what was reported from other parts of the country.[7],[8],[9],[10],[11]

Our finding of intracardiac thrombus as the most common form of cardiac masses is in keeping with previous reports [7] Thrombus commonly complicates myocardial infarction, DCM, and chronic left ventricular aneurysm. We had previously reported on the burden of LVT among patients with abnormal echocardiogram in our center, where DCM, ischemic cardiomyopathy, and PPCM were the leading predispositions.[12] Transthoracic echocardiography remains the de facto standard in the diagnosis of LVT, with a sensitivity of 90–95% and a specificity of 85–90%.[3]

Left atrial thrombus is known to complicate atrial fibrillation and rheumatic mitral stenosis.[14],[15] The majority of our findings of atrial thrombus involved patients with mitral stenosis, reflecting the existing burden of rheumatic heart disease in our environment. A higher proportion of left atrial thrombus was reported in Enugu, although the underlying predisposition was not mentioned.[7] On the other hand, atrial thrombus was not detected on transthoracic echocardiography among patients with rheumatic heart disease in Kano.[10] Because our report is based on transthoracic echocardiography, our finding of left atrial thrombus might not reflect its true occurrence since transesophageal echocardiography is required to establish its presence or otherwise with certainty.[16]

Vegetation formed the second largest group of cardiac masses in our series, with the majority complicating rheumatic valvular heart disease. A similar finding was reported in Kano, where 8.5% of patients with rheumatic heart diseases had vegetation.[10] All vegetations in our series are related to a regurgitant valve lesion, with 80% involving the mitral valve. Contrary to what was reported in Kano, we found two cases of vegetation involving the ventricular side of aortic valve, and a case of tricuspid valve involvement. Echocardiography has over the years, assumed a central tenant, with a clearly recognized fundamental importance in the management and follow-up of patients with infective endocarditis.[17] Major echocardiographic findings diagnostic of infective endocarditis are vegetation, abscess (periannular tissue devitalization), and dehiscence of the prosthetic valve.[18] Other findings include valve leaflet perforation and aneurysm. However, it is worth emphasizing that when applied out of context, the utility of echocardiography in the diagnosis of infective endocarditis diminishes.[19] Our ability to detect the other manifestations of infective endocarditis is hampered by lack of transesophageal modality.

The most common site for atrial myxoma is the left atrium, followed by the right atrium. However, all cases of presumed atrial myxoma in our series involved the right atrium. Myxoma was not suspected on clinical grounds in all our subjects. Two had pedunculated masses with attachment to the interatrial septum, prolapsing into the tricuspid valve in diastole [Figure 2]. Our findings differed from the Enugu experience, where all cases of myxoma were documented in the left atrium.[7] However, other workers have documented the occurrence of right atrial myxoma in Nigerians.[20],[21] Secondary metastases from renal cell carcinoma into the IVC could send finger-like extension into the right atrium.[22] One of our patients (a female) had a mass in the IVC [Figure 2] following excision of right atrial myxoma at an Indian hospital, but right atrial extension was not documented. Uterine tumors may as well present with IVC extension, though less common.[23] The patient in question had normal renal as well as gynecological imaging.

One case of metastatic pericardial mass from a hepatoma was diagnosed. Our diagnosis was based on echocardiographic findings of pericardial mass and effusion, supported by CT of the chest and abdomen. Secondary pericardial tumors due to metastases or local invasion from neighboring organs are much more common than primary tumors.[5],[6] Malignant pericardial tumors present as pericardial masses, plaques, or nodules with varying degrees of hemorrhagic effusion.[24] The prevalence of 0.1% in our report is similar to what was reported by other workers.[5]


  Conclusion Top


Cardiac masses are not uncommon findings among patients undergoing echo in our hospital. Its limitations notwithstanding, we believe that transthoracic echo can provide valuable information in the assessment of the various forms of cardiac masses, especially for cardiac thrombus in the setting of predisposing cardiac conditions. This can help in the choice of modalities of treatment, including of anticoagulants in those with cardiac thrombus to obviate the undesirable consequences of embolization.


  Limitation Top


Despite the pivotal role of transthoracic echocardiogram in the evaluation of cardiac masses, it has a number of limitations. Mural thrombus, particularly when layered, can be difficult to differentiate from the myocardium, leading to underdiagnosis. The different types of cardiac masses cannot be differentiated with certainty since echocardiography cannot provide histologic diagnosis. This makes most of our diagnoses at best, presumptive. Poor image quality consequent upon suboptimal acoustic access could result in reduced ability to image cardiac masses. Transthoracic echo has the obvious limitation of inadequate assessments of vegetation, abscesses and atrial thrombi.

Acknowledgment

Support of all the staff of echocardiography lab, as well as Medical Records Department is highly appreciated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Armstrong WF, Ryan T. Masses, tumors and source of embolism. In: Feigenbaum's Echocardiography. 7th ed.. Philadelphia, PA, USA: Lippincott Williams & Wilkins; 2010. p. 711-40.  Back to cited text no. 2
    
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Srichai MB, Junor C, Rodriguez LL, Stillman AE, Grimm RA, Lieber ML, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: A comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation. Am Heart J 2006;152:75-84.  Back to cited text no. 3
    
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Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol 2007;60:27-34.  Back to cited text no. 5
    
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Ejim EC, Anisiuba BC, Ike SO, Oguanobi NI, Ubani-Ukoma C, Essien I, et al. Intra-cardiac masses in adults: A review of echocardiogram records at two echocardiographic laboratories in Enugu, South-East Nigeria. Niger J Clin Pract 2013;16:468-72.  Back to cited text no. 7
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Kolo PM, Omotoso AB, Adeoye PO, Fasae AJ, Adamu UG, Afolabi J, et al. Echocardiography at the university of Ilorin teaching hospital Nigeria. A three years audit. Res J Med Sci 2009;3:141-5.  Back to cited text no. 8
    
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Adebayo RA, Akinwusi PO, Balogun MO, Akintomide AO, Adeyeye VO, Abiodun OO, et al. Two-dimensional and Doppler echocardiographic evaluation of patients presenting at Obafemi Awolowo university teaching hospitals complex, Ile-Ife, Nigeria: A prospective study of 2501 subjects. Int J Gen Med 2013;6:541-4.  Back to cited text no. 9
    
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13.
Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for chamber quantification: A report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440-63.  Back to cited text no. 13
    
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Shrestha NK, Moreno FL, Narciso FV, Torres L, Calleja HB. Two-dimensional echocardiographic diagnosis of left-atrial thrombus in rheumatic heart disease. A clinicopathologic study. Circulation 1983;67:341-7.  Back to cited text no. 15
    
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Manning WJ, Reis GJ, Douglas PS. Use of transoesophageal echocardiography to detect left atrial thrombi before percutaneous balloon dilatation of the mitral valve: A prospective study. Br Heart J 1992;67:170-3.  Back to cited text no. 16
    
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Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009;30:2369-413.  Back to cited text no. 18
    
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Sabageh D, Odujoko OO, Komolafe AO. Right atrial myxoma as a possible cause of hemorrhagic stroke and sudden death. Niger Med J 2012;53:102-4.  Back to cited text no. 21
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Cochennec F, Seguin A, Riquet M, Fabiani JN. Intracardiac renal cell carcinoma metastasis. Eur J Cardiothorac Surg 2008;34:697-9.  Back to cited text no. 22
    
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Moreno Antón F, Casado Herraez A, Puente Vázquez J, Gómez Díaz R, Aragoncillo P, Díaz-Rubio García E. Cardiac metastasis from uterine leiomyosarcoma. Clin Transl Oncol 2006;8:375-8.  Back to cited text no. 23
    
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