Particular echocardiographic aspect in a neoplastic patient

Introduction: Cardiac masses can be described as abnormal structures with origin in any cardiac struc-ture or as non-neoplastic masses (e.g. mural thrombi). Cardiac neoplasms are extremely rare, primary tumors consisting of only 5% of the total. Embolization is a comun phenomenon for both primary malignancies – preferentially localized in the left atrium (LA), and se-cond malignancies – frequently covered by thrombotic material, having emboligenic potential. In the majority of cases, they appear in advanced tumor disease, in ge-neralized tumor spread, when the patients have already undergone surgical treatment/chemo – radiotherapy.

Methods: We report the case of a 78-year-old patient, with a history of gastric carcinoma for which he un-derwent surgery and chemo and radiotherapy (2017), that still has an active pulmonary nodule on PET-CT (2018), paroxysmal recurrent atrial fibrillation, left jugular vein thrombosis, bilateral extensive iliofe-moral-popliteal deep venous thrombosis (2018) who presented for progressively installed rest dyspnea and right pleuritic pain. Clinical examination revealed ri-ght basal fine crackles and oxygen saturation of 89%. Thoraco-abdominal pelvic CT confirms pulmonary thromboembolism (PTE) and reveals partial thrombo-sis of infrarenal inferior vena cava (IVC), left ventricu-lar (LV) intracavitary nodular structured filling defects and osteocondensing lesions suggestive of secondary tumors.

Results: Echocardiography revealed multiple round-oval shaped, pediculated and sessile, highly echogenic, formations in the apical 1/3 of LV, medium 1/3 of ri-ght ventricle (RV) and on the LA face of the interatrial septum, biventricular dilated cardiomyopathy, severe systolic LV dysfunction (EF~20%) – newly appeared modifications since the last evaluation from 6 months before (EF~40%). After discharge, under anticoagulation therapy with Dalteparin, the patient suffered an ischemic cerebrovascular accident, while the echocar-diographic re-evaluation after a month of anticoagula-tion therapy showed the disappearance of the left in-traventricular formations and the persistance of those attached to the LV and to the LA side of the interatrial septum, as well as the systolic dysfunction.

Conclusions: T he etiology of this intermediate risk PTE in this patient is probably paraneoplastic – consi-dering the active pulmonary nodule on PET-CT, oste-ocondensing lesions, multiple episodes of deep venous thrombosis and the infrarenal IVC partial thrombosis – possibly the emboligenic source. The differential dia-gnosis of the left intracardiac formations is between „in situ“ thrombosis and tumors/metastases – most proba-bly from the pulmonary lesion. The persistence of some masses under correct anticoagulant suggests their ma-lignant origin, while the cerebrovascular accident can be seen as a tumor embolization from the LV masses. The particularity of this case consists in the echocar-diographic aspect and bilateral localization of the intra-cardiac masses, as well as the evolution of this patient.

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)