Int J Cardiovasc Imaging (2014) 30:1461–1462 DOI 10.1007/s10554-014-0462-4
IMAGES IN CV APPLICATIONS
Large cystic mass in the right atrium: multimodality imaging and pathologic features of a giant interatrial septal aneurysm Jamie M. Weiss • Mary Le • Shi-Kaung Peng Jina Chung
•
Received: 18 May 2014 / Accepted: 29 May 2014 / Published online: 27 August 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract The case demonstrates the use of echocardiography, cardiac computed tomography (CCT) and cardiac magnetic resonance imaging (CMRI) to determine the size, location, anatomic connection, perfusion and hemodynamic significance of a large tumor in the right atrium. The mass was surgically excised and pathology confirmed an ultimate diagnosis of an interatrial septal aneurysm (ISA). Transesophageal echocardiography enhances the sensitivity of detecting ISA and is the initial test of choice when an ISA is suspected on transthoracic echocardiography. In addition, the use of CCT and CMRI helps further define the anatomy, perfusion and tissue characteristics of the mass. Our case demonstrates the utility of multimodality noninvasive imaging to characterize an unusual tumor leading to a successful surgical treatment and a corresponding pathologic diagnosis of a large, cystic aneurysm of the interatrial septum. Keywords
Interatrial septal aneurysm Right atrial mass
Electronic supplementary material The online version of this article (doi:10.1007/s10554-014-0462-4) contains supplementary material, which is available to authorized users. J. M. Weiss (&) J. Chung Division of Cardiology, Harbor-UCLA Medical Center, 1124 West Carson Street, RB2, Box 405, Torrance, CA 90509, USA e-mail: [email protected] M. Le S.-K. Peng Department of Pathology, Harbor-UCLA Medical Center, Torrance, CA, USA
A 36-year-old woman with a life-long murmur presented with chest pain, syncope, and exertional dyspnea. Transthoracic echocardiogram (TTE) revealed a large, mobile cyst measuring approximately 3 cm in the right atrium. Transesophageal echocardiogram (TEE) showed the mass attached to the interatrial septum adjacent to a patent foramen ovale (PFO) (Panel A, Supplementary data online, Video 1). The mass remained echo-free with agitated saline injection, but opacified during left-sided filling with Definity (Panel B). During cardiac magnetic resonance imaging (CMRI), cine images showed the intermittent diastolic prolapse of the mass into the right ventricle. Delayed enhancement imaging ruled out fibroma or thrombus (Panel C). T1-weighted images pre- and postgadolinium and T2-weighted images with fat saturation ruled out lipoma, but showed vascular perfusion of the cystic lining (Panel D). The perfusion sequence demonstrated simultaneous perfusion of the cavity with the left atrium (Panel E, Supplementary data online, Video 2). Cardiac computed tomography (CCT) confirmed the aneurysmal cyst with a well-defined neck in the superior portion of interatrial septum and correlated well with the surgically excised mass during a pericardial patch repair (Panel F). H&E staining revealed a thin wall with a single layer of endothelial lining cells on either side entrapping discrete myocytes bundles and confirmed the diagnosis of an interatrial septal aneurysm (Panel G). This case demonstrates successful anatomic and hemodynamic characterization of an unusual intracardiac mass by multimodality imaging, leading to the diagnosis of a large, cystic aneurysm of the interatrial septum. The patient’s symptoms resolved following the repair (Fig. 1). Conflict of interest
None.
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Fig. 1 a TEE in a bicaval view showing the mass (yellow arrow) attachment near a PFO (top) and Doppler flow from the right atrium through the PFO (bottom) (LA, left atrium; RA, right atrium). b TEE in a bicaval view showing the unopacified mass (yellow arrow) with agitated saline contrast (top) and TTE in a four-chamber view showing opacification of the mass (yellow arrow) with Definity (bottom) (LA, left atrium; RA, right atrium). c CMRI cine images in a four-chamber view showing the mass (yellow arrow) prolapsing into RV (left) and delayed enhancement images showing no scar or thrombus (right). d CMRI T1-weighted spin echo (left) and T2weighted spin echo with fat saturation (middle) showing isointense cystic wall (yellow arrow) with endo/myocardium. T1-weighted spin echo post-gadolinium showing the hyperintense wall (right). e CMRI
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Int J Cardiovasc Imaging (2014) 30:1461–1462
perfusion sequence during right-sided filling (left) and left-sided filling (right) showing the simultaneous opacification of the mass (yellow arrow) and left atrium. f CCT 3-dimensional volumerendered image of the aneurismal cystic mass (yellow arrow) with a well-defined neck (asterisk) at its attachment to the interatrial septum (left) (LA, left atrium; LAA, left atrial appendage; RUPV, right upper pulmonary vein; RLPV, right lower pulmonary vein; LUPV, left upper pulmonary vein; LLPV, left lower pulmonary vein). Gross specimen of the excised aneurysmal cyst including wide margins at its attachment (asterisk) to the interatrial septum (right). g H&E stain showing myocyte bundles within a thin wall in low power (left) and high power (right)
IMAGES IN CV APPLICATIONS
Large cystic mass in the right atrium: multimodality imaging and pathologic features of a giant interatrial septal aneurysm Jamie M. Weiss • Mary Le • Shi-Kaung Peng Jina Chung
•
Received: 18 May 2014 / Accepted: 29 May 2014 / Published online: 27 August 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract The case demonstrates the use of echocardiography, cardiac computed tomography (CCT) and cardiac magnetic resonance imaging (CMRI) to determine the size, location, anatomic connection, perfusion and hemodynamic significance of a large tumor in the right atrium. The mass was surgically excised and pathology confirmed an ultimate diagnosis of an interatrial septal aneurysm (ISA). Transesophageal echocardiography enhances the sensitivity of detecting ISA and is the initial test of choice when an ISA is suspected on transthoracic echocardiography. In addition, the use of CCT and CMRI helps further define the anatomy, perfusion and tissue characteristics of the mass. Our case demonstrates the utility of multimodality noninvasive imaging to characterize an unusual tumor leading to a successful surgical treatment and a corresponding pathologic diagnosis of a large, cystic aneurysm of the interatrial septum. Keywords
Interatrial septal aneurysm Right atrial mass
Electronic supplementary material The online version of this article (doi:10.1007/s10554-014-0462-4) contains supplementary material, which is available to authorized users. J. M. Weiss (&) J. Chung Division of Cardiology, Harbor-UCLA Medical Center, 1124 West Carson Street, RB2, Box 405, Torrance, CA 90509, USA e-mail: [email protected] M. Le S.-K. Peng Department of Pathology, Harbor-UCLA Medical Center, Torrance, CA, USA
A 36-year-old woman with a life-long murmur presented with chest pain, syncope, and exertional dyspnea. Transthoracic echocardiogram (TTE) revealed a large, mobile cyst measuring approximately 3 cm in the right atrium. Transesophageal echocardiogram (TEE) showed the mass attached to the interatrial septum adjacent to a patent foramen ovale (PFO) (Panel A, Supplementary data online, Video 1). The mass remained echo-free with agitated saline injection, but opacified during left-sided filling with Definity (Panel B). During cardiac magnetic resonance imaging (CMRI), cine images showed the intermittent diastolic prolapse of the mass into the right ventricle. Delayed enhancement imaging ruled out fibroma or thrombus (Panel C). T1-weighted images pre- and postgadolinium and T2-weighted images with fat saturation ruled out lipoma, but showed vascular perfusion of the cystic lining (Panel D). The perfusion sequence demonstrated simultaneous perfusion of the cavity with the left atrium (Panel E, Supplementary data online, Video 2). Cardiac computed tomography (CCT) confirmed the aneurysmal cyst with a well-defined neck in the superior portion of interatrial septum and correlated well with the surgically excised mass during a pericardial patch repair (Panel F). H&E staining revealed a thin wall with a single layer of endothelial lining cells on either side entrapping discrete myocytes bundles and confirmed the diagnosis of an interatrial septal aneurysm (Panel G). This case demonstrates successful anatomic and hemodynamic characterization of an unusual intracardiac mass by multimodality imaging, leading to the diagnosis of a large, cystic aneurysm of the interatrial septum. The patient’s symptoms resolved following the repair (Fig. 1). Conflict of interest
None.
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Fig. 1 a TEE in a bicaval view showing the mass (yellow arrow) attachment near a PFO (top) and Doppler flow from the right atrium through the PFO (bottom) (LA, left atrium; RA, right atrium). b TEE in a bicaval view showing the unopacified mass (yellow arrow) with agitated saline contrast (top) and TTE in a four-chamber view showing opacification of the mass (yellow arrow) with Definity (bottom) (LA, left atrium; RA, right atrium). c CMRI cine images in a four-chamber view showing the mass (yellow arrow) prolapsing into RV (left) and delayed enhancement images showing no scar or thrombus (right). d CMRI T1-weighted spin echo (left) and T2weighted spin echo with fat saturation (middle) showing isointense cystic wall (yellow arrow) with endo/myocardium. T1-weighted spin echo post-gadolinium showing the hyperintense wall (right). e CMRI
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Int J Cardiovasc Imaging (2014) 30:1461–1462
perfusion sequence during right-sided filling (left) and left-sided filling (right) showing the simultaneous opacification of the mass (yellow arrow) and left atrium. f CCT 3-dimensional volumerendered image of the aneurismal cystic mass (yellow arrow) with a well-defined neck (asterisk) at its attachment to the interatrial septum (left) (LA, left atrium; LAA, left atrial appendage; RUPV, right upper pulmonary vein; RLPV, right lower pulmonary vein; LUPV, left upper pulmonary vein; LLPV, left lower pulmonary vein). Gross specimen of the excised aneurysmal cyst including wide margins at its attachment (asterisk) to the interatrial septum (right). g H&E stain showing myocyte bundles within a thin wall in low power (left) and high power (right)
