A  case  report  fromHenri  Mondor  hospital

Ismahen  Ben  Yaacoub,  Julie  Mayer,  AlainLuciani,  Hicham  Kobeiter,  AlainRahmouni,  Jean-­‐François  Deux

Mr  B.,  48  year-­‐old

• Medical  history  :

– Appendicectomy

– Family  history  (sister)  of  primiJve  dilatedcardiomyopathy  with  EF=30%

– Current  smoker  (15  cigarets/day)

• Experienced  2  lipothymies  with  transient  chest  pain

• AdmiYed  in  the  emergency  unit  15  days  ago  during  thesecond  event:

– Biology  -­‐,  Electrocardiogram  -­‐,  chest  x-­‐ray  -­‐

– No  hospitalizaJon,  no  treatment

• Stress  echocardiography  scheduled

Rest  TTE4  chamber  view

3D  SA  views

Rest  TTE• What  do  you  see  ?

• An  intraLV  tumorregarding  lateral  segmentHyperechogenicity Fine  limitaJonsMobile Located  betweentrabeculaJons

• An  inferobasalhypokinesis

Rest  TTE• Management  ?

• No  stress  test  (risk  ofembolic  event)

• Cardiac  MRI  required  inorder  to  precise  thenature  of  the  lesion

• CT  scan  was  notperformed  in  first  lineto  limit  X-­‐ray  exposure

Cardiac  MRI

• Cine  MR  (SSFP  sequence)

Cardiac  MRI

• What  do  you  see  ?

• An  intraLV  tumor:

• mobile  lesion

• broad-­‐based  lesion

• An  hykokinesis  of  theinferior  wall

Black  blood  imaging

• FSE  T1w • STIR  T2w

Gadolinium  injecJon

• Perfusion

• 3D  LE

• BB  T1

• PSIR  

Finally…

• Intra  LV  tumor  +  inferior  myocardial  infarcJon

• Your  diagnosis  ?

• First  hypothesis:  it  is  a  MI  with  a  thrombus  !• Possible  but:

• Thrombus  is  located  near  necrosis  andnot  strictly  in  contact  with  the  MI

• MRI  detected  an  enhancement  of  the«  thrombus  »  :  it  is  possible  butunfrequent,  usually  enhancemet  isevidenced  in  old  marginated  thrombus

Second  hypothesis• MR  evidenced  2  disJnct  lesions:  a  MI  and  acardiac  tumor  !

• The  tumor  as  a  bening  appearance  on  MRexaminaJon

• Can  we  link  these  2  diagnosis  ?

• Yes,  if  we  suppose  that  MI  has  an  embolic  origin

• Benin  tumor  +  coronary  embols    the  mostevident  diagnosis  is  ….

CARDIAC MYXOMA

Other  examinaJons

• Brain  MRI:– Small  high  signalareas  detected  inthe  white  matersuggesJng  emboliclesions

• Coronarography  examinaJon:

The  paJent  was  transferred  in  cardiacsurgery

• A  4  cm  gelaJnous  ovoid  lesion  was  excised

• The  lesion  was  located  in  the  lem  ventriculebetween  trabeculaJons

• A  pedunculated  stalk  was  evidenced  duringsurgery

• Histological  analysis:  cardiac  myxoma

Cardiac  myxoma

• Most  commun  primary  cardiac  tumor  of  the  heart

• ≈  5%  of  myxomas  are  located  in  ventricules

• Embolic  phenomena:  second  most  commun  clincalmanifestaJon  (30-­‐40%  of  paJents)

• But  coronary  embolizaJon  are  rare  (0.06%),  morefrequent  in  the  inferior  territory  (63%  of  cases)

• MRI:– hypo/iso  intense  on  T1W,  hyperintense  on  T2W– Heterogenous  enhancement  amer  gadolinim  injecJon

• Therapy:  surgical  excision

Grebenc et al; Radiographics 2000;20:1073-103