Author + information
- Usha Manian, MD,
- Olusegun Sheyin, MD,
- Rodrigo Bagur, MD, PhD,
- Bob Kiaii, MD and
- Nikolaos Tzemos, MD∗ (, )@LHSCCanada
- ↵∗Division of Cardiology, Department of Medicine, Western University, London, Ontario, N6A 5A5, Canada
Left-sided cardiac masses (LSCM) are a rare finding with an estimated incidence of between 0.002% to 0.2% in the general population (1). Most are identified following symptoms related to cardiac or cerebrovascular systems or at postmortem examination (2). Asymptomatic left heart masses are challenging cases to diagnose due to their rarity, variety, and paucity of specific symptoms. Most LSCM are diagnosed as benign primary cardiac tumors (1). Therapy for benign cardiac tumors is surgical resection to reduce embolic risk but is generally dependent upon symptoms, type of tumor, and anatomical location (2). Surgical resection of myxomas and papillary fibroelastomas (PFE) provides excellent outcomes with minimal sequelae (3,4). With advances in cardiac imaging, detection of cardiac masses is increasing. However, there is limited guidance about clinical management strategies in patients with an incidental finding of LSCM. In this prospective study, we followed patients incidentally found to have LSCM to determine embolic risk and help determine further management of this subset of patients.
We included 44 consecutive patients with incidental discovery of an LSCM who presented to hospital for a variety of reasons, from health screening to trauma (Table 1). None of the patients had specific cardiac or cerebrovascular complaints at the time of the discovery. Patients with a known history of coronary artery or cerebrovascular disease were excluded from the study. After the initial imaging modality (Table 1) that serendipitously identified the LSCM, all patients provided informed consent to participate in the study. They all underwent cardiac mass characterization with dedicated imaging protocol using cardiac magnetic resonance imaging with late gadolinium enhancement for myocardial fibrosis, cerebral imaging with computed tomography (CT), and brain magnetic resonance imaging for the assessment of silent ischemic lesions. To exclude other possible sources of systemic embolism, we then performed 48-h Holter monitoring, duplex carotid ultrasound, and contrast enhanced transthoracic echocardiography on all patients. Coronary imaging with CT angiography or invasive angiography was subsequently performed to exclude concomitant obstructive coronary artery disease. Thereafter, all patients underwent elective surgical resection of the cardiac mass, and histology was performed on resected tissue.
Mean age was 52 ± 16 years with a female predominance of 32 of 44 (73%). Of the 44 patients, 23 (52%) patients had evidence of multivessel (2 or more) coronary territory subendocardial myocardial infarction (defined as <25% of the transmural myocardial wall) detected by cardiac magnetic resonance imaging. A total of 16 (36%) patients had multifocal silent ischemic cerebral embolism detected by brain magnetic resonance imaging.
Histology revealed that 19 of 44 (43%) masses were myxomas, 15 of 44 (34%) were PFE, 6 of 44 (14%) were left ventricular thrombi, and 2 of 44 (5%) were lipomas. Subclinical embolic events occurred in 12 of 19 (63%) patients with myxomas, 11 of 15 (73%) patients with PFE, and 2 of 6 (33%) patients with left ventricular thrombi.
Our study shows that incidentally found LSCM in asymptomatic patients have an unexpectedly, and perhaps unacceptably, high prevalence of subclinical myocardial and cerebral ischemic events.
Surgical resection of myxomas is recommended due to high embolic risk and cardiac complications (5). Surgical excision of PFE is generally only performed when the tumor is >1 cm in size or considered highly mobile. For all other instances of LSCM, conservative management with close monitoring is advised (2). However, distinguishing between the different types of cardiac masses from imaging alone is difficult, therefore making management decisions challenging. Our study shows that there were no clinical or diagnostic differences between the individuals who had embolic events compared to those who did not.
The findings of our study provide valuable insight into the pathogenesis of symptoms due to LSCM with indolent embolization to cardiac and cerebral targets. Unexpectedly, the majority of the previously mentioned LSCM were not associated with symptoms, providing further support to the chronicity of the disease and its natural history.
This study suggests that regardless of the size or appearance of LSCM, subclinical embolic events are occurring at an alarming rate, supporting growing evidence in this area (4). Asymptomatic LSCM carry a significant burden of cardiovascular morbidity, calling for early surgical resection following diagnosis.
Please note: Dr. Kiaii has served as a consultant for Medtronic, Edwards Lifesciences, and Boston Scientific, but are not relevant to the contents of this paper. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
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