|Number 09-16: A large and mysterious mass in the LV|
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.
Image 2. TEE, 4-chamber view.
To futher characterize this mass, the patient underwent a CMR scan.
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.
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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