Unsual right ventricle outflow tract obstruction by cardiac mass

Presenting Author(s)

• 

  Maira Azevedo Ximenes

  Fellowship in Cardiac Imaging Department DASA + Unifesp
  Universidade Federal de São Paulo - Unifesp
  São Paulo, Sao Paulo, Brazil

Primary Author(s)

• 

  Maira Azevedo Ximenes

  Fellowship in Cardiac Imaging Department DASA + Unifesp
  Universidade Federal de São Paulo - Unifesp
  São Paulo, Sao Paulo, Brazil

Co-Author(s)

• MC

  Marcia de Paula Cardinali

  Fellowship in Cardiac Imaging DASA-SP
  Universidade Federal de São Paulo - Unifesp, Brazil
• CP

  Cecilia Maria Pereira Pereira Santos

  Fellowship in Cardiac Imaging DASA-SP
  Universidade Federal de São Paulo - Unifesp
  São Paulo, Sao Paulo, Brazil
• 

  Gabriel Amaral Mendes Ferreira, MD

  Cardiologist
  Universidade Federal de São Paulo - Unifesp/ DASA
  Sao Paulo, Sao Paulo, Brazil
• TN

  Thiago Marchini Naves

  Grupo de imagem cardiovascular DASA-SP
  Universidade Federal de São Paulo - Unifesp, Brazil
• 

  Marly Uellendahl, MD, PhD

  Cardiac Imaging Coordinator
  DASA - UNIFESP
  São Paulo, Sao Paulo, Brazil
• LA

  Luciano de Figueiredo Aguiar Filho

  Grupo de imagem cardiovascular DASA-SP
  Universidade Federal de São Paulo - Unifesp, Brazil
• RP

  Robinson Poffo

  Heart surgeon in Hospital Moriah
  Universidade Federal de São Paulo - Unifesp, Brazil
• SC

  Sergio Curcio

  Heart surgeon in Hospital Moriah
  Universidade Federal de São Paulo - Unifesp, Brazil
• AB

  Adriana Brentegani

  Heart surgeon in Hospital Moriah
  Universidade Federal de São Paulo - Unifesp, Brazil
• DH

  Dina Mie Hatanaka

  Anesthesiologist in Hospital Moriah
  Universidade Federal de São Paulo - Unifesp, Brazil
• MM

  Matheus Miranda

  Hospital Moriah
  Universidade Federal de São Paulo - Unifesp, Brazil
• AT

  Alexandre Teruya

  Hospital Moriah
  Universidade Federal de São Paulo - Unifesp, Brazil
• FJ

  Flavia Pegado Junqueira

  Radiologist in DASA-SP
  Universidade Federal de São Paulo - Unifesp, Brazil
• AR

  Alfredo Rodrigues, MD

  Coordenador do Grupo de Imagem Cardiovascular DASA-SP
  Universidade Federal de São Paulo - Unifesp
  Sao Paulo, Sao Paulo, Brazil

Description of Clinical Presentation: Cardiac masses (or tumors) are rare compared to other cardiac comorbidities, and due to their nonspecific symptoms, their diagnosis can be challenging for the medical team. In the right ventricle, they present as thrombi, lipoma, or tumors such as rhabdomyoma, fibroma, lymphoma, or metastasis. Access to more detailed imaging tests such as cardiac magnetic resonance imaging (CMR) can differentiate diagnostic hypotheses and guide specific treatment.
A 21-years-old young woman from the state of São Paulo (Brazil), previously asymptomatic, developed exertional dyspnea in early 2025. Neither she nor her family have had a previous history of similar symptom. Laboratory tests were unremarkable. A transthoracic echocardiogram revealed a poorly defined mass in the right ventricle, which was difficult to visualize through the acoustic window. CMR was requested for detailed characterization of the finding.

Diagnostic Techniques and Their Most Important Findings: CMR was performed.Steady-state free precession sequences reveal preserved ventricular function, increased right ventricular volume, and a heterogeneous, predominantly hypointense image with regular, elongated edges. The image is multipedunculated, somehow adherent to the right ventricular (RV) free wall, reaching the chamber's outflow tract and promoting signs of local obstruction. Perfusion sequences of the right two chambers and RV outflow tract demonstrate minimal peripheral perfusion of the mass and a lobular center that was not perfused by the first pass of gadolinium contrast. Late enhancement sequences show heterogeneous contrast enhancement, more evident in the peripheries, and a very hypointense center. Findings suggest atypical right ventricular myxoma. The patient underwent cardiac surgery for tumor resection, and anatomopathological analysis, two days after the procedure, revealed findings that favor a diagnosis of cardiac myxoma. She remains hospitalized for postoperative clinical stabilization.

Learning Points from this Case: In the reported case, the cardiac tumor image was atypical, making the exact diagnosis difficult. However, due to the visualization of the RV outflow tract obstruction, a resolution of the clinical picture becomes more imperative. CMR aids in the detailed characterization of cardiac masses and is an excellent imaging method to guide the medical team in continuing patient care.

Steady State Free Precession sequences
Perfusion sequences
Late Gadolinium Enhancement sequences