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Number 09-16: A large and mysterious mass in the LV
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Number 09-16: A large and mysterious mass in the LV 

Case from: Tarek M. Mousa, Gorgi Kozeski, M. Rizwan Khalid, Saji Abraham, Ola Akinboboye. Department of Internal Medicine, Section of Cardiovascular diseases, Integrated Cardiac Imaging Laboratory, New York Hospital Medical Center of Queens, Flushing, NY, USA 

Clinical history: A 59 y/o female with history of breast CA s/p right lumpectomy and ovarian CA was referred for CMR for evaluation of an abnormal structure in the left ventricle found incidentally on a breast MRI. The EKG was normal (Image 1) as well as the chest X-ray.

 

 

 

Image 1. Twelve leads ECG (Click to enlarge).

 

Transthoracic echocardiography (TTE) (Image 2) showed a large pedunculated echo-dense mass attached to the apex and protruding towards the base, measuring 6.4cm in the long axis and 2.4cm in the short axis. The mass appears attached to the apex and does not thicken during systole.
These findings were confirmed also by transesophageal echo.

 

  

Image 2. TEE, 4-chamber view.

 

To futher characterize this mass, the patient underwent a CMR scan.
The mass was nearly iso-intense with myocardium on the spin echo, T1-weighted, and T2-weighted sequences. Cine MRI images revealed attachment of the mass to the apex, and diffuse akinesia of the apical regions with absent systolic thickening (Image 3 and Movie 1).

 

   

Image 3. Two-chamber view (still frame)                                     Movie 1. Two-chamber view cine

 

Inversion recovery imaging sequence after the administration of gadolinium demonstrated the presence of transmural apical late enhancement (consistent with a LAD territory infarction), and the mass under investigation appeared to be an endocavitary thrombus formation (Image 4). The diagnosis was reached based on its characteristic signal intensity after gadolinium (notable low signal intensity, ie. no vascularity) but also considering that it was adjacent to an akinetic infarcted area. 

 

 

Image 4. Two-chamber LGE.

 

Perspective: CMR in this patient complemented the TTE in demonstrating a previously silent apical myocardial infarction with large associated thrombus. The explanation for this unsually shaped and large thrombus remains unclear, but a hypercoagulable state from ovarian CA is a plausible cause.  

References:

1) Barkhausen J, Hunold P, Eggebrecht H, et al. Detection and characterization of intracardiac thrombi on MR imaging. AJR Am J  Roentgenol. 2002; 179:1539-1544

2) Sparrow PJ, Kurian JB, Jones TR, Sivananthan MU. MR imaging of cardiac tumors. Radiographics. 2005; 25:1255-1276.

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COTW handling editor: Chiara Bucciarelli-Ducci

 

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