Intra Cardiac Mass – A Diagnostic And Therapeutic Dilemma.
Dr Shilpi Mohan,Dr Abhay Kumar,Dr Niraj Kumar,Dr Madhukar Shahi,

Department of Cardiology
Artemis Health Institute , Sector 51, Gurgaon 122001

INTRODUCTION

Peripartum cardiomyopathy is a rare cause of heart failure with a reported incidence of 1 per 3000 to 1 per 4000 live births and a fatality rate of 20-50% in first year(1). It initially presents with signs and symptoms of congestive heart failure and rarely with thromboembolic complications. We report an unusual case of peripartum cardiomyopathy in a previously healthy postpartum woman who presented with multiple mobile clots in left ventricle which were successfully treated with anticoagulants.

Case report

 A 25 years old female presented to our emergency room with complaints of progressively increasing dyspnoea on exertion, paroxysmal nocturnal dyspnoea and orthopnea of 15 days duration. She was not a known case of rheumatic heart disease, congenital heart disease, hypertension, diabetes or cardiomyopathy. She had no febrile illness in the recent past. She had delivered a healthy baby three months back without any complications and was asymptomatic during her last month of pregnancy and early post partum period.
                   On general examination , she was conscious and had no neurological deficit. Facial puffiness and lower limb pitting edema were noticeable. Her vitals were stable and  jugular venous pressure was raised . On cardiovascular examination, LVS3 was present. Bilateral inspiratory crepts were present till mid thoracic region. Transthoracic echocardiography was done which showed global hypokinesia, LVEF 15%. Multiple 

Correspondence : Dr (Mrs) Shilpi Mohan Department of Cardiology, Artemis Health Institute , Sector 51, Gurgaon 122001, Haryana India
Email:shilpi2708@gmail.com,  shilpi2708@rediffmail.com

Two of the masses showed intramass hypoechogenecity. Mild MR , AR and TR were present and there was evidence of moderate pulmonary arterial hypertension. Cardiac MRI was done to differentiate between clot and tumour so as to plan further management. It suggested multiple intracardiac clots attached to the lateral wall of the left ventricle [Figure 2(a), Figure 2(b)]. Based on the history, clinical examination and non invasive cardiac evaluation, the diagnosis of peripartum cardiomyopathy , severe LV dysfunction with intracardiac clots was made. She was treated with decongestants, anticoagulants. INR was targeted between 2-3 and after stabilization, she was discharged on anti-failure treatment and anticoagulants-LMWH and Acitrom. She was reviewed after 2 weeks. Repeat ECHO showed no improvement  in LV systolic function but more than 90% of the clots had resolved [Figure 3(a), Figure 3(b)]. Patient is symptomatically better and has been continued on oral anticoagulants.

DISCUSSION

The differential diagnosis of an intracardiac mass  includes thrombus, tumour or vegetation. Some of the anatomical variants mimic  such as eustachian valve, chiari network, crista terminalis,

pectinate muscle, right ventricular moderator band or an interatrial septal aneurysm mimic cardiac mass. These normal variants more often involve right sided chambers and are found incidentally. Coronary or an aortic aneurysm, lipomatous hypertrophy of interatrial septum, a hiatus hernia or a catheter / pacemaker lead may also mimic a cardiac mass and are known as “pseudotumours”(2-5). An echo artifact such as the near field clutter, reverberations or a side lobe artifact could also be mistaken for a mass.

Cardiac MRI is a very good imaging tool to differentiate various intracardiac masses.  The major advantages of CMR include larger field of view of both cardiac and extracardiac structures, multiplanar 3-D imaging, excellent inherent natural tissue contrast and the ability to characterize tissue with increased water, fat or soft tissue contents by their varying degrees of magnetized T1 or T2 weighted relaxation times. Gadolinium contrast enhancement pattern of increased capillary perfusion help to study the extent of vascularity of a mass(4,5). Thrombus demonstrates increased signal intensity on T1 weighted image due to oxyhemoglobin or deoxyhemoglobin and lower signal intensity on gradient echo cine images and it does not demonstrate gadolinium contrast enhancement. Chronic thrombi have

uniformly low signal on T2 weighted image compared with a tumour. An organized clot however may demonstrate intermediate heterogenous areas of enhancement that may be mistaken for a cardiac tumour such as a myxoma(6,7). Primary benign cardiac tumour such as lipoma, rhabdomyoma or a fibroma and a hemangioma have variable heterogeneity and signature tissue characteristics that are typical for the individual tumour  or CMR imaging(3,4,5). Cardiac MR imaging thus provides a more definitive diagnosis of the cardiac mass and helps to plan appropriate therapeutic strategies for the patients.

Evaluation of the response of the mass to anticoagulation to determine etiologic diagnosis may cause unnecessary delay in diagnosis; whereas surgical resection may be too aggressive an approach or not feasible in several cases.

About one third of the patient with dilated cardiomyopathies have left ventricular thrombi(8).The  rate of systemic embolization seen with mobile thrombi is high. Definitive treatment of these intracardiac thrombi are not well established. Oral anti-coagulation has shown a resolution rate of 13-59%(9). Thrombolysis with urokinase, streptokinase and t-PA has been reported but the risk of hemorrhagic or embolic complications are unacceptably high(10).