An unusual left ventricular apical mass

Erika Cavallero; Mirko Curzi; Sara Anna Cioccarelli; Giulio Papalia; Diego Ornaghi; Renato Maria Bragato

doi:10.4103/2211-4122.143986

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CASE REPORT

Year : 2014 | Volume : 24 | Issue : 3 | Page : 95-96

An unusual left ventricular apical mass

Erika Cavallero¹, Mirko Curzi¹, Sara Anna Cioccarelli¹, Giulio Papalia¹, Diego Ornaghi², Renato Maria Bragato¹
¹ Division of Echocardiography, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
² Heart Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy

Date of Web Publication

5-Nov-2014

Correspondence Address:
Erika Cavallero
Division of Echocardiography, Humanitas Clinical and Research Center, via Manzoni - 56, 20089 Rozzano (Mi)
Italy

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2211-4122.143986

Abstract

Left ventricular apical masses constitute a rare finding. Imaging properties together with the clinical history of the patient usually allow an etiologic definition. We report a challenging case of an ambiguous left ventricular apical mass of uncertain nature till histological examination. Points of interest were singular clinical history and echocardiographic findings, although not conclusive in hypothesis generating. Furthermore to the best of our knowledge, this is one of the rare attempt to excise a deep left ventricular mass with a mini-invasive surgical approach.

Keywords: Echocardiography, left ventricular mass, multimodality diagnosis, mini-invasive excision

How to cite this article:
Cavallero E, Curzi M, Cioccarelli SA, Papalia G, Ornaghi D, Bragato RM. An unusual left ventricular apical mass. J Cardiovasc Echography 2014;24:95-6

How to cite this URL:
Cavallero E, Curzi M, Cioccarelli SA, Papalia G, Ornaghi D, Bragato RM. An unusual left ventricular apical mass. J Cardiovasc Echography [serial online] 2014 [cited 2022 May 26];24:95-6. Available from: https://www.jcecho.org/text.asp?2014/24/3/95/143986

Introduction

Left ventricular masses constitute a rare echocardiographic finding in the general population. With careful attention to its location and morphology and appropriate application of clinical information, echocardiography can usually distinguish between the three principal intracardiac mass lesions: tumor, thrombus and vegetation. ^[1] We report a challenging case of an ambiguous left ventricular apical mass of uncertain nature till histological examination. The anomaly was discovered during an echocardiographic evaluation done because of a recent cerebrovascular ischemic event.

Case report

A 67-year-old male presented to the emergency room because of a transient confusion episode one week before. He had a silent past personal medical history. Physical examination was negligible, whilst the electrocardiogram showed the presence of atrial fibrillation and T wave inversion in V3-V6 leads. Non-contrast-enhanced computed tomography (CT) scanning of the brain detected a hypodense area within left insular cortex. Doppler echography of supra-aortic arteries was unremarkable. Transthoracic echocardiogram demonstrated a 18 × 10 mm oval-shaped, homogeneous, echo dense, highly mobile mass floating in left ventricular apex [Figure 1]a and b]. Concomitant findings were dilated left atrium without a significant mitral regurgitation, and dilated left ventricle with severely depressed global function (EF = 25%) in presence of akinetic apex. The intracardiac mass was characterized by pronounced mobility, lack of an identifiable peduncle (thus supposed to be faint), regular borders without capsule and homogeneous texture similar to myocardium (closer to the texture of vascularized tissues than to that of fibrotic or thrombotic structures). Coronary angiography showed no significant stenosis. Cardiac magnetic resonance imaging (MRI) excluded contrast enhancement of the mass, anyway its accuracy was limited by reduced temporal resolution in presence of atrial fibrillation and pronounced mass mobility. Owing to the embolic risk and the unaltered aspect after seven days of anticoagulant therapy, the patient underwent successful surgical excision through a video assisted Port Access approach [Figure 1]c and d].

Figure 1: (a) Apical four chamber view. (b) Parasternal short axis view at the apical level. (c) Trans-mitral mass view deep in left ventricular apex through right thorax HeartPort approach. (d) Excised white apical mass with its narrow stalk

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Histopathologic examination identified organized hematic material configuring a white thrombus. Recovery was rapid and uncomplicated, optimal medical treatment for heart failure together with oral anticoagulant therapy was administered and well tolerated. Pre-discharge control echocardiography on the sixth day revealed a mild recovery in left ventricular function with a 35% ejection fraction, in the absence of apical thrombus recurrence.

Discussion

According to the literature left ventricular apex is a rare site of origin for cardiac tumors, whilst it is most commonly involved in thrombotic stratifications of established cardiomyopathy. ^[1] Confounding elements in the exposed scenario came both from imaging properties of the mass, as from the clinical history of the patient who presented completely asymptomatic from a cardiological standpoint. Myxoma is the most common cardiac neoplasm, but it usually arises from interatrial septum presenting with heterogeneous echo-density. Fibroelastoma predominantly involves papillary muscles and cardiac valves, with shimmering edges. Fibroma is generally diagnosed in infants and young adults as a ventricular intramural mass.

High embolic risk and lack of an etiologic diagnosis imposed resection, anyway left ventricle severe contractile dysfunction conferred a high risk profile for a traditional surgical excision through ventriculotomy. ^[2] The combination of endoscopic views to Port Access allowed deep transmitralic thrombus visualization and its gentle pull for estraction. ^[3] Histopathologic examination identified organized hematic material configuring a white thrombus. The mechanism proposed to account for its development is segmental akinesia of sub-acute subendocardial infarction due to coronary embolization in the context of silent atrial fibrillation in idiopathic cardiomyopathy. ^[4]

Acknowledgements

Our sincere gratitude to the Cardiac Sonographer Papalia Giulio and Dr. Cioccarelli Sara Anna for their support and contribute in the management of this complex case.

References

1.	Peters PJ, Reinhardt S. The echocardiographic evaluation of intracardiac masses: A review. J Am Soc Echocardiogr 2006;19:230-40.
2.	Lee JM, Park JJ, Jung HW, Cho YS, Oh IY, Yoon CH, et al. Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents. J Atheroscler Thromb 2013;20:73-93.
3.	Tanaka D, Unai S, Diehl JT, Hirose H. Surgical removal of a large mobile left ventricular thrombus via left atriotomy. World J Clin Cases 2014;2:32-5.
4.	Egolum UO, Stover DG, Anthony R, Wasserman AM, Lenihan D, Damp JB. Intracardiac thrombus: Diagnosis, complications and management. Am J Med Sci 2013;345:391-5.