Rare Intracardiac Cystic Mass in an Adult: Diagnostic Contribution of CMR

Presenting Author(s)

• 

  Eugenia Pomeraantz, MD

  Cardiologist specialized in advanced cardiovascular imaging
  Hospital Italiano de Buenos Aires
  1425, Ciudad Autonoma de Buenos Aires, Argentina

Primary Author(s)

• 

  Eugenia Pomeraantz, MD

  Cardiologist specialized in advanced cardiovascular imaging
  Hospital Italiano de Buenos Aires
  1425, Ciudad Autonoma de Buenos Aires, Argentina

Co-Author(s)

• SG

  Sebastian Oscar Ghibaudo, MD

  Cardiologist specialized in advanced cardiovascular imaging
  Sanatorio Anchorena de Recoleta, Buenos Aires, Argentina
• LA

  Luis Ivan Almiron, MD

  Cardiologist specialized in cardiovascular imaging
  Sanatorio Anchorena de Recoleta, Buenos Aires, Argentina
• NL

  Nicolas Lalor, MD

  Head of the Department of Cardiology
  Sanatorio Anchorena de Recoleta, Buenos Aires, Argentina
• MM

  Maria de la Paz Ricapito Maria de la Paz Ricapito

  Central de Especialidades Médicas,, Mexico

Description of Clinical Presentation: We present the case of a 43-year-old female patient, born in Taiwan and residing in Argentina since 1996. She had no cardiovascular risk factors and a past medical history of two cesarean sections. She was referred to our center for further evaluation after the incidental echocardiographic finding of an intracardiac mass attached to the mitral valve (MV), initially suspected to be a hydatid cyst. The patient was asymptomatic, with unremarkable physical examination. The electrocardiogram showed sinus rhythm without significant abnormalities.

Diagnostic Techniques and Their Most Important Findings: On admission, a transesophageal echocardiogram (TEE) revealed a heterogeneous mass (solid and cystic components), sessile, attached to the ventricular surface of the posterior mitral leaflet, measuring 21.9 x 18.6 mm, with limited mobility, no flow within on color Doppler, and preserved valvular function. The initial presumptive diagnosis was hydatid versus blood cyst (Figure 1).
Abdominal angiotomography demonstrated multiple heterogeneous cystic liver lesions with centripetal enhancement (largest 51 x 56 mm), suggestive of hemangiomas with atypical behavior. At cardiac level, the mitral valve mass was confirmed as a filling defect, with no additional findings.
Cardiac magnetic resonance imaging (CMR) provided more accurate tissue characterization: the mass was firmly attached to the ventricular surface of segment P1 of the posterior mitral leaflet, cystic in appearance, with mixed content (solid and liquid) and limited mobility. Cine SSFP sequences showed fluid signal with a small solid component inside; isointense on FSE T1 and hyperintense on FSE T2 and T2 STIR relative to myocardium. There was no perfusion on first-pass gadolinium and no late gadolinium enhancement on PSIR sequence at 10 minutes (Figure 2).
Serologic tests (VDRL, HIV, hepatitis B and C, hydatidosis) and blood cultures were all negative.
Since no other lesions compatible with hydatidosis were identified, the leading presumptive diagnosis was a cardiac blood cyst, although hydatid cyst and atypical hemangioma could not be ruled out given the hepatic findings. Considering the large size of the mass and the high risk of embolic complications, surgical resection was indicated.

Learning Points from this Case: This case highlights the value of CMR in tissue characterization of cardiac masses, allowing for a more accurate presumptive diagnosis, as well as its role in determining benignity and local extension, which are essential in guiding therapeutic decision-making.

Figure 1. TEE findings: A) Mid-esophageal at 0°, four-chambers view and B) Transgastric at 0°, short axis view at mitral valve level: sessile mass with mixed content attached to the ventricular surface of the posterior leaflet of the mitral valve, with no color Doppler flow within.
Figure 2. RMC findings: Three-chambers view. A) Cine SSFP sequence: Mass firmly attached to the ventricular surface of segment P1 of the posterior mitral leaflet, cystic in appearance, with mixed content (solid and liquid) and limited mobility. B) FSE T1 sequence: isointense and C) FSE T2 STIR sequence: hyperintense relative to myocardium. D) First-pass gadolinium sequence without perfusion. E) and F) PSIR sequences at early and late gadolinium enhancement respectively without enhancement.