Case Session
SCMR 22nd Annual Scientific Sessions
JiaHao Hu, MD
Medical Resident
Aurora St. Luke's Medical Center of Aurora Health Care Metro, Inc.
Matthew McDiarmid, DO
Cardiology Fellow
Aurora Health Care
Tonga Nfor, MD, MPH
Physician Faculty
Aurora St. Luke's Medical Center of Aurora Health Care Metro, Inc.
Patrycja Galazka, MD
Cardiologist
Aurora St. Luke's Medical Center of Aurora Health Care Metro, Inc.
John Crouch, MD
CV/TXP Surgeon
Aurora St. Luke's Medical Center of Aurora Health Care Metro, Inc.
Jay Webb, MD
Medical Resident
Aurora St. Luke's Medical Center of Aurora Health Care Metro, Inc.
Rahul Sawlani, MD
Director of Cardiothoracic Imaging
Aurora St. Luke's Medical Center of Aurora Health Care Metro, Inc.
Description of Clinical Presentation: A 58-year-old male two months status post non-ST elevation myocardial ischemia (NSTEMI) due to now stented posterior descending artery (PDA) stenosis presented to the emergency department with fatigue, elevated troponin of 1.64, and first-degree AV block.
Diagnostic Techniques and Their Most Important Findings:
Transthoracic echocardiogram demonstrated a moderate pericardial effusion and decreased LVEF of 44% (previously 56%) as well as right atrial diastolic collapse. Patient was again taken to the catheterization lab, revealing a patent PDA stent and 40% stenosis distal to the stent with no further intervention.
Due to ongoing chest pain, a pulmonary embolus CT was performed, which was negative for PE but questioned a 3.9 cm soft tissue lesion at the posterior interatrial septum. Cardiac MRI was ordered both to evaluate the mass and suspected pericarditis. The cardiac MRI demonstrated a well-defined, immobile mass centered in the interatrial septum and invading the right atrium. The mass demonstrated intermediate to high T2 intensity, evidence of internal blood products, and post-contrast T1 enhancement but no arterial phase enhancement on first-pass perfusion imaging. MRI also showed pericardial inflammation on delayed enhancement and T2 black-blood imaging.
The location of the mass in concert, previous solitary severe PDA stenosis, and lack of coronary calcium on comparison imaging all prompted a follow-up coronary CT angiogram, which showed that the PDA disease was likely due to mass effect. There was no evidence of coronary artery disease.
That night, the patient coded due to ventricular fibrillation and was resuscitated. The patient’s labile rhythm was attributed to the mass, so cardiac surgery was consulted. On admission day 10, the mass was resected with reconstruction of the atrium via bovine patch. Pathology revealed a malignant epithelioid hemangioendothelioma with aggressive features.
Learning Points from this Case: This presentation will describe the MR characteristics observed in this rare primary cardiac tumor and address the value of multi-modality imaging (particularly cardiac MRI) in this case. This tumor has been sparsely described in the literature, and to our knowledge, its characteristics on cardiac MRI have not previously been reported.