BRIEF REPORTS

Left Ventricular Apical Masses: Noninvasive Differentiation of Rare

from Common Ones

ANDRE KEREN, MD TOSHIHIKO TAKAMOTO, MD DONALD C. HARRISON, MD

RICHARD L. POPP, MD

Previous investigator@ have described 2-dimensional echocardiographic (2-D echo) features of uncommon cardiac masses. The value of 2-D echo criteria in dis- tinguishing these masses from thrombi has not been analyzed systematically. We designed this study to as- sess the usefulness and limitations of clinical and 2-D echo criteria in differentiating among distinct types of LV apical masses.

A search of our data bank for patients in whom good quality 2-D echocardiograms showing obvious masses in- volving the LV apical area yielded 3 patients with apical hypertrophic cardiomyopathy and 4 patients with apical tumor. We included a similar number of patients with apical

From the Cardiology Division, Stanford University School of Medicine, Stanford, California. This work was supported in part by an Israeli Heiden Fellowship Grant and by Fogarty Fellowship F05 TWO 3416-01-81, from the National Institutes of Health, Bethesda, Maryland. Dr. Keren’s Present address is the Heiden Department of Cardiology, Bikur Cholim Hospital, Jerusalem, Israel. Dr. Takamoto is supported by a Research Fellowship funded by the Ministry of Education of Japan. Manuscript received July 12, 1984; revised manuscript received April 8, 1985, accepted April 9, 1985.

thrombi for comparative analysis (Table I). The final diag- nosis was reached in 10 of 11 patients by pathologic evalua- tion of biopsies or of the masses removed at surgery and ne- cropsy. In a young, asymptomatic Nigerian black man (patient 6), the diagnosis was based on the presence of symmetrically inverted T waves 20 mm deep in the left pre- cordial leads and a ‘spade-like” narrowing of the apical cavity on 2-D echocardiography, with localized hypertrophy of the apex. 2 The 2-D echocardiograms were recorded in the standard fashion using ultrasound imaging systems (Hew- lett-Packard 7702OAC or Toshiba SSH-IOA) with a 2.25- or 3.5-MHz medium or short focused transducer. The criteria used to define left ventricular thrombus and apical hyper- trophy were those stated in previous reports.lA Apical tumor was suspected when the mass did not fulfill the criteria for either thrombus or hypertrophy and showed inhomogeneous ultrasonic appearance, demarcation from but extension into the myocardium, gross or bizarre distortion of the cardiac anatomy and presence of pericardial effusion. 1,5 The 2-D echocardiograms were also evaluated for the presence or absence of 12 specific visual characteristics.

One investigator assessed the recorded history, physical examination, standard 12-lead electrocardiogram (ECG) and chest x-ray (Table I) plus the information that an LV apical mass was present to render a diagnosis. Another investigator assessed the Z-D echocardiograms alone to render a diag- nosis, and then he was given the clinical data and again asked to identify the nature of the apical mass. Neither in- vestigator knew the pathologic findings or the proportion of patients with any diagnosis within this study group. Each investigator might choose the single correct diagnosis (+3 points), list an alternative diagnosis after (+2 points) or before (+l point) the correct one, be unable to choose among the 3 diagnoses (0 points), list only a single but incorrect diagnosis (-1 point) or list only the 2 incorrect diagnoses (-2 points). Thus a perfect diagnosis of all 11 patients would yield

TABLE I Clinical and Pathology Findings in 11 Patients with Left Ventricular Apical MeSS

Age W Positive Findings Coronary Pt & Sex History (Examination, ECG, X-Ray) Disease* Morphology

: 69M Ml, dyspnea, syncope CHF, MR, VT, LBBB, cardiomegalyt LAD, right, LC Thrombus 72M MI, CVA, chest pain Old MI, VPCs LAD, right Thrombus

3 62M HBP, MI, LV aneurysm, CHF, MR, old MI, VT, cardiomegaly LAD, right LC Thrombus chest pain, dyspnea, syncope

4 56M HBP, MI, LV aneurysm, CHF, MR, LVH, old MI, calcified LAD, LC Thrombus dyspnea aneurysm, cardiomegaly

5 73F HPB, dyspnea, syncope CHF, MR, AF, St-T changes, LVH LC Apical hypertrophy cardiomegaly

6 24M Car accident Extreme ST-T changes, LVH 0

-2 7 6OF Bilateral mastectomy, CHF, AF, VT, ST-T changes Apical hypertrophy

CVA, chest pain, dyspnea cardiomegaly 8 46F Retroperitoneal mass, CHF, MR. ST-T changes, lung - Adenocarcinoma

CVA, dyspnea metastases, cardiomegaly 9 32F Chest oain ST-T changes, LVH, VT, cardiomegaly, 0 Fibroma

75F Ml, chest pain, dyspnea 16F Mandibular cyst, dyspnea

apical calcifications CHF, MR, old Ml, cardiomegaly, MAC LBBB, VT, cardiomegaly

LAS 0

Fibroma Fibroma

l Presence of 270% coronary obstruction. t Cardiothoracic ratio >50%. t Diagnosis of apical hypertrophy based on clinical and 2-D echo crtteria (see text). AF = atrial fibrillation; CHF = congestive heart failure; CVA = cerebrovascular accident; LC = circumflex coronary artery; iiBP = high blood

pressure; LAD = left anterior descending coronary artery; LBBB = left bundle branch block; LVH = left ventricular hypertrophy; MAC = mitral anulus calcification; Ml = myocardial infarction; MR = mitral regurgitation; VPCs = ventricular premature complexes; VT = ventricular tachycardia; - = no information available; 0 = absent or negative.

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698 BRIEF REPORTS

a score of 33; the accuracy and certainty of diagnosis were expressed by a percentage score index (score/33 X 100).

The differential diagnostic accuracy of the methods used is expressed in Table II. The clinical eualuation was useful in defining patients with thrombus and with metastatic cardiac tumor. Because 88 to 99% of cardiac metastases found at necropsy have been associated with primary or secondary intrathoracic malignancy,6 the x-ray findings of pulmonary masses in patient 8 (Table I) directed the diag- no.?9 LO cardiac tumor. Clinical assessment showed 2 major limitations: symptoms and physical examination were noncontributory; and there were no pathognomonic features to aid in recognition of primary-cardiac tumors or apical hypertrophy. In 2 of our 3patients with apical hypertrophy, the ECG showed only nonspecific ST-T changes.3 A similar ECG pattern, however, was found in most of our patients with tumor. The 2-D echocardiogram improved recognition of apical hypertrophy. Nevertheless, all methods were im- perfect in differentiating the apical tumors from thrombi.

There was lack of specificity of visual 2-D echo criteria; 6 of the 12 visual characteristics analyzed were scattered among the 3 categories of masses. These criteria were fea- tures related to the mass: strictly apical, symmetric, smooth free edges and presence of calcified areas; and absence of apical diameter narrowing and pericardial effusion. Table III includes the other 6 characteristics that were present in all patients in at least 1 category of mass, although not confined to 1 category necessarily. Wall motion patterns adjacent to and remote from the mass were found to differ

TABLE II Diagnostic Accuracy* of Methods Used in Differentiating Left Ventricular Apical Masses

Apical Thrombus Hypertrophy Tumor Total

(n = 4) (n = 3) (n = 4) (n = 11)

Method Clinical 100% 44% 50% 2-D echo 100% 88 % 50% :2 2-D echo + clinical 100% 88% 75% 882

l The diagnostic accuracy is represented for each method studied as achieved score/maximal perfect score X 100 (see text).

2-D echo = P-dimensional echocardiography.

in the 3 categories. Patients with thrombus had both local akinesialdiskinesia and abnormal wall motion in areas re- mote from the mass. All 4 patients with tumor had normal wall motion remote from the apex and 3 of these had severe apical asynergy. All patients with apical hypertrophy had mild apical hypokinesia and normal remote wall motion. Patients with apical hypertrophy had all 6 characteristics listed in Table III in common (i.e., the feature was either present or absent in all). Moreover, active contractility of the mass was a finding specific for these patients, probably representing the major differential diagnostic criterion

compared with other categories of apical masses. Our results confirmed the presence of previously described criteria in all patients with thrombi, but revealed their lack of specificity owing to frequent occurrence in patients with tumors. The finding of an apical mass that is visible throughout the car- diac cycle, has clear demarcation from the myocardium ad- jacent to an area of severe myocardial asynergy,lT4 and is without active contractility of the mass during systole was present in all of our patients with thrombi, but also was seen in 3 patients with apical tumor (Fig. 1).

These results support the combined use of clinical and 2-D echo data for optimal diagnosis of left ven- tricular apical masses but additionally suggest the need

TABLE Ill Two-Dimensional Echocardiographic Visual Criteria

Thrombus Apical

Hvoertroohv Tumor

Abnormal adjacent wall motion

Abnormal remote wall motion

Mass: demarcated

+(A/D) +0-f) +(H/A/D)

+ 0 0

+ 0 VP from myocardium

Mass: active contractility 0 + 0 Mass texture

Different from the VP 0 VP myocardium

Nonuniform VP 0 VP

A = akinesia; D = dyskinesia; H = hypokinesia; 0 = absent or negative: VP = characteristic variable but present in most patients in a group; + = present in all patients.

October 1. 3985 TE AXRICAN :DtiRNAi 6i; CARDIOLOGY Volume 56 69

for improved 2-D echo or other tissue characterization methods to provide more direct information and better segregation of tumors from thrombi. Our few patients with apical hypertrophic cardiomyopathy had several group characteristic 2-D echo features that may help differentiate this entity from apical thrombi.

. s

4.

References 1. Ports TA, Cogan J, Schiller NB, Rapaport E. Echocardiography of left ven-

tricular masses. Circulation 1978;58:528-536. 2. Yamaguchl H, lshimura T, Nishiyama S, Nagasaki F, Nakanishi S, Takatsu

5.

6.

F, Nishijo T, Umeda T, Uachii K. Hypertrophic non-obstrucbve cardiomy- opathy with giant negative T waves (apical hypertrophy): ventricuiographic and echocardiographic features in 30 patients. Am J Cardiol 1979;44: 401-412. Maron BJ, Borrow RQ, Seshagiri TNR, Roberts WC, Epstein SE. Hypetirophic cardiomyopathy with ventricular septal hypertrophy localized to the apical region of the left ventricle (apical hypettrophic cardiomyopathy.) Am J Cardiol 1982;49:1838-1848.

$tratton FR, Lighty GW, Pearlman AS, Ritchie JL. Detection of left ventricular thrombus by twodimensional echocardiography: sensitivity, specificity and causes of uncertainty. Circulation 1982;66:156-166. Bogren HG, DeMaria AN, fvlason DT. Imaging procedures in the detection of cardiac tumors, with emphasis on echocardiography: a review. Cardiovasc Intervent Radio1 1980;3:107-125. Wanfling SM. Metastatic cancer of the heart. Review of the literature and report of 127 cases. Firculation 1960;22:474-483.

Pericardial Defect Mimicking Left Atrial Mass

BARRY S. TALESNICK, MD FREDERICK J. SUTTON, MD

YU-CHEN LEE, MD JOSEPH S. MCLAUGHLIN, MD

a fibrotic tissue led to the echocardiographic appearance of a nonmobile LA mass behind the posterior mitral leaflet. The appearance of the pericardial defect sug- gested a congenital origin. We believe that this is the first reported case of a pericardial defect presenting as an LA mass.

Left atria1 (LA) tumor and thrombus are the most common causes of abnormal intraatrial echoes. Extra- cavitary echoes mimicking intracardiac masses have not been reported. We report a patient with a pericardial defect in whom post-traumatic pericardial adhesions were responsible for the echocardiographic appearance of an LA mass.

A 23-year-old man was referred for 3-artery systolic myocardial bridging. The patient had a l-year history of retrosternal chest pain after an automobile accident. Ex- amination and chest x-ray were normal. The electrocardio- gram displayed a sinus rhythm, a PR interval of 0.24 second and right-axis deviation (16OO). Two-dimensional echocar- diography (long-axis and subxiphoid views) suggested a large mass fixed to the posterior LA wall behind the posterior mitral valve leaflet (Fig. 1 and 2). The patient underwent incision of the myocardial bridging and LA exploration. No intracavitary mass was visualized or palpated. However, a large, round posterior pericardial defect was seen with the pericardial rim adherent to and compressing the LA wall. Adhesions were lysed between the left atrium and parietal pericardium. A coronary artery bypass graft to the distal circumflex and incision of the left anterior descending myocardial bridge was performed.

Echocardiography had enhanced the clinical ability to recognize intracardiac masses and may have greater sensitivity than any other diagnostic technique.l Al- though false-positive and false-negative studies are occasionally encountered using M-mode echocardiog- raphy,2*3 2-dimensional techniques tend to clarify confusing studies. In this case we postulate that post- traumatic inflammatory changes in the pericardium contribute to fibrosis and adhesions between the edge of the pericardial defect and left atrium. An extrinsic compressive effect on the posterior left atrium by the

From the Division of Cardiology, University of Maryland Hospital, 22 South Greene Street, Baltimore, Maryland 2 1201. Manuscript received February 7, 1985; revised manuscript received March 11, 1985, ac- cepted March 20, 1985.

FIGURE 1. Two-dimensional echocardiogram-parasternal long- axis view. AML = anterior mitral leaflet; A0 = aortic root; IVS = interventricular septum; LA = left atrium; LV = left ventricle; RV = right ventricle; f = left atrial echoes suggestive of a mass lesion.

FIGURE 2. Schematic representation of Figure 1. Abbreviations as in Figure 1.