An image is worth a thousand words

Introduction: T he incidence of multiple intracardiac masses is rare and they are mainly characterized throu-gh echocardiography, but the differential diagnosis is done between thrombi, vegetations and tumors.

Methods: We present the case of a 77 years old patient, known with left bundle branch block (LBBB), chronic obstructive pulmonary disease stage III GOLD, whi-ch presented at the emergency room (ER) for severe dyspnea on rest up to orthopnea and unproductive cough, symptoms worsened in the last days. The pa-tient had 4 admissions in the last 4 months with the presumed diagnosis of infectious exacerbation of pul-monary disease. From history and clinical exam we thought that it was an episode of decompensation of heart failure, with moderate leg swelling and subcrepi-tant rales in the basal half of the thorax, bilaterally. The electrocardiogram showed sinusal tachycardia with 114/min and major LBBB. The thoracic radio-graphy revealed global cardiomegaly and left pleural effusion in low quantity. The echocardiography in the ER indicated global increased size of cardiac cham-bers, with a left ventricle ejection fraction (LVEF) of 10-15% with global severe hypokinesia of LV. The right ventricle (RV) was dilated with McConnel sign and a ovalar-round shaped echogenic mass of 30/20 mm on the lateral wall of apical RV. The computed tomography of the lung with contrast showed a minimal (residual) thromboembolism on segmentar branches of left infe-rior lobar artery and confirmed the hypodense mass without contrast in RV.

Results: After stabilization, the patient is reevaluated on echocardiographic laboratory where the optimal conditions permitted the visualisation of a round-ova-lar shaped hyperechogenic mass (43/43 mm) on the chordae tendineae of the tricuspid valve (TV) and a filiform structure of 57 mm with its own mobility on the septal cusp of TV, suggesting the presence of ve-getations, besides the antero-apical mass on the RV wall. In the absence of MRI availability in our hospital, the intraventricular structure was considered to be a thrombus, the patient having favorable conditions for this pathology (the decrease in the velocity of the blood and the recent diagnosed PE), and the structures found on the tricuspid valve apparatus was interpreted as ve-getations, the patient receiving adequate anticoagulant and antibiotic treatment.

Conclusions: The case report showed the dual etiology of an acute heart failure: thromboembolic pathology cu thrombus in RV and infectious endocarditis of a pati-ent with dilatative cardiomyopathy with severe reduced LVEF of unspecified etiology. The particularity of our case is the presence of an en-docarditis of right heart in the absence of an evident risk factor and clinical signs and symptoms suggesting infectious disease, but the imaginf methods permitted the adequated diagnosis and treatment. Under right treatment the two types of intracardiac masses disap-peared during the hospitalisation.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)