Differential diagnosis of cardiac masses using contrast echocardiographic perfusion imaging
James N. Kirkpatrick, MD*,
Tiffany Wong, MD*,
James E. Bednarz, BS, RDCS*,
Kirk T. Spencer, MD, FACC*,
Lissa Sugeng, MD*,
R. Parker Ward, MD, FACC*,
Jeanne M. DeCara, MD, FACC*,
Lynn Weinert, BS*,
Thomas Krausz, MD, FRCPath* and
Roberto M. Lang, MD, FACC*,*
* Adult Noninvasive Cardiac Imaging Laboratories, Section of Cardiology; and the Department of Pathology, University of Chicago, Chicago, Illinois, USA
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Figure 1 (A) A mass filling the right atrium (apical five-chamber view). (B) The mass hyper-enhanced with echocardiographic contrast, compared with the adjacent myocardium. (C) There was no enhancement of the mass or the adjacent myocardium after a high-mechanical index impulse destroyed contrast bubbles, ruling out "false-positive perfusion" of the mass. (D) The biopsy specimen diagnosis was follicular thyroid carcinoma. The blood vessels are stained with CD31 antibody. (E) Perfusion curves of video intensity over time demonstrated greater values for A and ß for the mass than for the adjacent myocardium.
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Figure 2 (A) A mass adjacent to the lateral wall of the left ventricle (apical four-chamber view). (B) There was hyperenhancement of the mass, relative to the adjacent myocardium. (C) There was no enhancement of the mass or the adjacent myocardium after a high-mechanical index impulse destroyed microbubbles. (D) A biopsy specimen stained with factor VIII antibody demonstrated extensive vascularity in a poorly differentiated adenocarcinoma. (E) Perfusion curves of video intensity over time demonstrated greater values for A and ß for the mass than for the adjacent myocardium.
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Figure 3 (A) A left ventricular apical mass (apical four-chamber view). (B) The mass showed no enhancement with contrast, whereas the adjacent myocardium demonstrated enhancement. (C) There was no enhancement of the mass or adjacent myocardium after a high-mechanical index impulse destroyed the contrast agent. (D) The surgical specimen demonstrated no staining with CD34 antibody and minimal cellularity, consistent with thrombus. (E) Perfusion curves of video intensity over time demonstrated no increase in video intensity in the mass from baseline, whereas video intensity increased within the myocardium.
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Figure 4 (A) A left ventricular apical mass (apical four-chamber view). (B) The mass hyper-enhanced with contrast, relative to the adjacent myocardium. (C) There was no enhancement of the mass or adjacent myocardium after a high-mechanical index impulse destroyed the contrast agent. (D) The surgical specimen was diagnosed as a hemangioma with abundant, dilated, thick-walled vessels, demonstrated by staining with factor VIII antibody. (E) Perfusion curves of video intensity over time demonstrated greater values for A and ß for the mass than for the adjacent myocardium.
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Figure 5 (A) A computed tomographic scan of the chest with contrast demonstrating an intracardiac mass (white arrow) and a hypodense area in the lung parenchyma (yellow arrow). (B) Apical four-chamber view of the left ventricular (LV) apical mass (white arrow) and the mass extrinsic to the LV apex (yellow arrow). (C) The LV apical mass failed to enhance with contrast, whereas the extrinsic mass hyper-enhanced, relative to the myocardium, and demonstrated large vascular channels (yellow arrow). (D) There was no enhancement of the masses or adjacent myocardium after a high-mechanical index impulse destroyed the microbubbles. (E) The biopsy specimen of the extrinsic mass showed a well-differentiated adenocarcinoma with multiple vascular channels stained with CD34 antibody. Lacking pathologic correlation, the intracardiac mass was not included in the comparison of contrast perfusion with VAI and does not appear in Table 2. (F) Perfusion curves of video intensity over time demonstrated greater values for A and ß for the mass than for the adjacent myocardium and no increase in intensity from baseline for the intracardiac mass. The intracardiac mass was presumed to be a thrombus.
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