Incidental cardiac tumor: the key role of Cardiac MRI in the characterization of cardiac masses

Description of Clinical Presentation: A 76-year-old male patient with a medical history of type 2 diabetes mellitus, dyslipidemia, active smoking, and chronic alcohol-related liver disease (Child-Pugh A5) was admitted to the Neurosurgery Department due to a chronic subdural hematoma with acute bleeding following a traumatic brain injury while intoxicated. During monitoring in the ICU, he developed new-onset atrial fibrillation.

A transthoracic echocardiogram performed as part of the evaluation revealed preserved systolic function without segmental wall motion abnormalities and moderate-to-severe mitral regurgitation associated with multiple masses attached to the posterior subvalvular apparatus, the largest measuring 2.5 cm (Figure 1).

Diagnostic Techniques and Their Most Important Findings: Transesophageal echocardiography revealed three oval-shaped isoechoic masses with poor perfusion after contrast administration, along with a smaller lesion on the tricuspid valve apparatus. Biventricular function was preserved.

Cardiac magnetic resonance imaging (CMR, 1.5 T) identified three well-defined intracardiac masses, isointense on T1, hyperintense on T2, without fat suppression, and showing heterogeneous peripheral late gadolinium enhancement, without myocardial infiltration, multicameral involvement, or pericardial effusion (Figure 2). The masses measured 20×13 mm, 11×26 mm, and 14×15 mm, respectively (Figure 3).

The left ventricular ejection fraction (LVEF) was 56%, and the right ventricular ejection fraction (RVEF) was 54%, with no resting perfusion defects. Additionally, a triangular subendocardial area of late enhancement was observed in the mid anterolateral wall, consistent with an embolic infarction.

Tissue characterization with CMR was decisive in ruling out thrombi or malignant neoplasms, pointing instead toward benign tumors, most likely multiple hemangiomas.

Learning Points from this Case: CMR imaging has proven to be fundamental in the assessment of cardiac masses, not only in characterizing malignancy but also in providing prognostic information. Malignant masses identified by CMR are associated with higher mortality, and there is excellent concordance with histopathology in differentiating malignancy [1].

In our patient, although multiple masses were present, the absence of major criteria for malignancy described in the literature (myocardial infiltration, multicameral involvement, pericardial effusion, diffuse late enhancement) [1,2], along with a pattern of heterogeneous peripheral enhancement, allowed classification as benign. This information was crucial in avoiding invasive procedures in a frail patient with recent intracranial hemorrhage.

1. Multimodality imaging (echocardiography + CMR) provided a comprehensive assessment: both hemodynamic impact and tissue characterization.


2. Integration of validated malignancy criteria supported a conservative follow-up approach, considering the masses as benign tumors.

This case illustrates how CMR serves as an essential clinical decision-making tool when biopsy is not feasible or carries high risk [1,2].

Masses Located in the Mitral Subvalvular Apparatus Causing Anterior Leaflet RestrictionTransesophageal and Transthoracic Echocardiogram: ● (A) Two-chamber and long-axis views showing restricted opening of the posterior mitral leaflet due to the presence of the masses. ● (B) 3D zoom view of the mitral valve from the ventricular side, revealing two masses larger than one centimeter, the largest measuring 2.8 cm × 2 cm. ● (C) Transthoracic echocardiogram using the contrast agent Sonovue, showing an isoechoic image at the level of the subvalvular apparatus. ● (D) Four-chamber view of the left ventricle demonstrating a large intracardiac mass.
1. SSFP sequence at the short-axis level shows a well-defined mass with regular borders, located in the subvalvular region and attached to the posterior papillary muscle. 2. No perfusion defects are observed at rest. 3. T1-weighted sequence with fat suppression demonstrates isointense masses at the level of the papillary muscles. 4. Late gadolinium enhancement is noted within the masses, heterogeneous in appearance, predominantly thick peripheral enhancement with central hypointense areas
1. TIR short-axis sequence demonstrates oval-shaped masses with well-circumscribed margins, attached to the subendocardium without infiltration, located at the level of the posterior papillary muscle, measuring 14.7 × 13.6 mm, with hyperintensity. 2. TIR short-axis sequence shows oval-shaped masses with well-circumscribed margins, attached to the subendocardium without infiltration, located at the posterior papillary muscle, measuring 10.9 × 26.1 mm. 3. Transesophageal echocardiography reveals hypoechoic masses at the subvalvular level. 4. TIR short-axis sequence demonstrates oval-shaped masses with well-circumscribed margins, attached to the subendocardium without infiltration, located at the posterior papillary muscle, measuring 20 × 12.9 mm.