A case of cardiac tumour

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A case of cardiac tumour

• Dr. Prateek Suri

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66 Yr old patient Mrs.G presented with

• Progressive shortness of breath and chest pains
  on exertion for a few weeks

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B/G

• Type 2 DM
• Hypertension
• CLL
• Previous Leiomyoma of stomach operated in 2002
• Dyslipidemia
• Asplenia

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B/G contd.

• Partial thyroidectomy-nontoxic goitre
• Obesity
• 50 stenosis of rt. internal carotid artery

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medications

• Atenolol
• Lercanidipine
• Irbesartan
• Nexium
• Metformin
• Rosuvastatin

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B/G

• Clinical examination - normal
• No relevant family history
• Bloods - nad
• Ecg - nad

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Investigations

• Exercise stress test Normal
• TTE 3.2 cm x1.2 cm mass in mitral valve annulus
  encroaching on to posterior mitral leaflet most
  likely a fibro sarcoma or marked annular
  localised calcification.

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Types of primary cardiac tumours

• Benign eg. myxoma,lipoma,fibroelastoma,
• Malignant eg. Angiosarcoma,fibrosarcoma,leiomyosar
  coma
• Benign or malignant eg. Mesothelioma,paragangloma

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Clinical picture

• Constitutional symptoms
• Embolic manifestations
• Cardiac complications eg. blood flow impairment
  or conduction abnormalities
• Metastatic disease

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Goals in a patient with suspected cardiac tumour

• To confirm if its present or not.
• If present its exact location and extent
• Whether its benign or malignant

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Investigations

• T.T.E
• T.O.E
• Cardiac MRI
• Cardiac CT
• PET
• Crdiac biopsy

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TOE result

• A mobile mass 1cm in diameter with a pedicle
  attached to the lateral wall /mitral valve
  annulus junction
• Annulus appears thickened and has increased
  echogenicity.

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Basics of MR imaging

• It relies on positively charged hydrogen
  atoms(protons) located in water molecules
• Normally each proton is a spinning positive
  charge and generates a small magnetic field
  around it.

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• The small magnetic fields of each proton allign
  themselves with the powerful magnetic field of
  the superconducting magnet
• When a patient is placed in a magnetic field
  these protons begin to spin at a frequency that
  is proportional to the strength of the magnetic
  field called the LARMOR frequency

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• A relatively small magnetic field called a
  gradiant is then applied in addition to the
  constant magnetic field causing protons at
  specific locations to rotate with slightly
  different frequencies.
• A radiofrequency energy pulse is then applied by
  the RF coil to the protons which has the same
  frquency as the protons spinning in the desired
  imaging location.

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• Rf pulse delivers energy only to protons with a
  different frequency to the rest of the
  protons(area of interest)which pushes their
  magnetisation direction away from the direction
  of the large magnetic field

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• When the radiofrequency pulse is stopped the
  selected protons relax back to their original
  allgnment with the large magnetic field releasing
  RF energy which is captured by a receiver to
  yield information about the protons in patients
  tissues

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• T1 its the time taken for 63 of the original
  magnetisation to recover after the RF pulse has
  stopped.
• T2 its the time taken to lose 63 of the
  original value of transverse magnetisation after
  the RF pulse is stopped

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Pulse sequences

• These are a pattern of radiofrequency waves and
  magnetic gradiants that are used to produce an
  image
• The 2 main types used in cardiac mri are
• -Gradiant echo
• -Spin echo

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Gradiant echo(bright blood technique)

• Workhorse of cardiac mri due to its speed and
  versatility and is used to assess valve
  function,ventricular function,myocardial
  perfusion and MRA

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SPIN ECHO(Dark blood technique)

• Its used to study the anatomy of the hear and
  blood vessels
• There is little artifact from metal but requires
  breath holding

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Steady state free precession(SSFP)

• Its a modification of gradiant echo that is the
  backbone of cine cardiac MR and produces
  excellent contrast between the myocardium and the
  blood

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Contrast agents

• MRI is sometimes performed with the use of IV
  contrast agents to enhance the signal of
  pathology or to better visualise the blood
  vessels.
• The paramagnetic effects of gadolinium causes a
  shortening of the T1 relaxation time causing
  areas with gadolinium to be bright on T1 weighted
  images
• Dose 0.1mmol/kg (0.2cc/kg)

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ECG GATING

• Ecg gating allows for stop motion imaging by
  acquiring data only during a specified period of
  the cardiac cycle typically during diastole when
  the hear is not moving
• The R wave is used as a reference point with data
  acquisition being initiated following a delay
  after the R wave

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Cine imaging

• These are short movies that are able to show
  heart motion throughout the cardiac cycle
• These are obtained by ECG triggerred segmented
  imaging with each cardiac cycle being divided
  into 10 -20 segments

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Inversion recovery pulses

• These are used to null the signal from a
  desired tissue to accentuate surrounding pathology

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Advantages of cardiac mri

• Non ionising hence safe in children and pregnancy
• Produces good quality images
• Low risk of allergy with gadolinium
• No interference from bone or air
• Less user dependent compared to echo

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Disadvantages of cardiac mri

• Patient cooperation is vital
• 5 patients experience severe claustrophobia
• Less spatial resolution than ct for checking
  coronary arteries
• Expensive and time consuming
• Metallic objects and implants contraindicated

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Cardiac mri report

• Small lobulated mass 3x2 cm arising from the left
  ventricular aspect of the posterior mitral
  leaflet extending to the mitral valve annulus
  likely to be a fibroelastoma

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Papillary fibroelastoma

• 2nd most common benign cardiac tumour in adults
  BUT most common one to affect the heart valves
• It resembles a sea anemone with frond like arms
  emanating from a central core.

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Histology

• A central core of dense acellular collagen
• A peripheral rim containing coarse fragmented
  elastin fibres
• Surface lining is one of endothelium

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Epidemiology

• Size from 2mm to 70 mm
• Mean 9mm
• Aortic valve is more commonly involved(36)
  followed by mitral valve(29)
• 9 are multiple
• (Am.Heart j. SEP 2003)

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Incidence

• Extremely rare various series have reported an
  incidence of lt0.1
• In a report published in Am.J.Cardiology jan 1996
  which compared 22 series found an incidence of
  .02 0r 200 tumours in a million autopsies.
• Secondary tumours on the other hand are at least
  20 times as common and have been documented in
  20 patients dying of metastatic cancer in some
  series.(Jou. Italian Card. 1996 jan)

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Coronary angiogram with left and right heart
catheterization

• Normal LV function
• Mild mitral regurgitation
• Mild pulmonary hypertension
• Mild coronary artery disease -30 stenosis in
  proximal and mid LAD and mid Circumflex.

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January 2009

• Patient presented to Maitland hospital with a
  left MCA territory infarct with slurred speech
  and difficulty in comprehension.
• MRI done revealed multiple infarcts in left MCA
  territory ,an acute right cerebellar infarct and
  old infarct in right parietal lobe suggestive of
  a cardioembolic source.

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Patient discharged in february from Maitland
hospital and started on warfarin.
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Patient referred for second cardiac MRI to St.
Georges Hospital sydney.

• 18X13 mm lesion attached to the free wall of the
  left atrium at the junction of the mitral annulus
  and associated mitral calcification
• On high resolution cine images it has some mobile
  elements making it more likely to be a
  fibroelastoma

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March 2009

• Aspirin was added to warfarin
• It was decided to keep observing patient and felt
  that embolism was probobaly due to clot and not
  tumour

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TREATMENT OF FIBROELASTOMA

• SURGERY-its indicated if
• There are embolic episodes
• Tumour size is greater 1cm
• Complications related to tumour eg. Coronary
  ostial occlusion
• Wait and watch

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• THANK YOU..