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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

You can change the size and the format of the image or video loops by using the links below the image or video loop.
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Loop Text Key  
Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Something is Wrong with the Right Side
Case#: 26
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
46 yo WF with hx of SOB and a left lower lobe mass on CXR. The patient had an excisional biopsy of her leg, breast, and right ventricular free wall 2 years ago. The leg and right ventricular free wall tumors were sarcomas. The breast tumor was breast cancer.

What is the differential diagnosis of the cardiac lesion?
What is the most likely cause of her cardiac lesion?
What is the cause of her SOB?


Case Discussion/CME Questions
The echo shows about a 2 cm discrete tumor in the apex of the right ventricle and right ventricular free wall akinesis. The tricuspid valve has mild regurgitation. The RV, RA, IVC and, hepatic veins are dilated.  The pulmonary valve is normal. The left ventricle and aortic valve are normal.

Cardiac tumors are rare with an incidence of less than 0.1%. Metastatic tumors are about 20 times more common than primary tumors. Primary cardiac tumors are more likely to be benign than malignant. About 75 percent of primary cardiac tumors are benign. Of the benign tumors, myxomas are the most common, about 50%. Other benign cardiac tumors are rhabdomyomas, fibroma, papilloma, hemangioma, and familial myxomas. Of the malignant primary tumors, over 95% are sarcomas (rhabdomyosarcoma, angiosarcoma).   Cardiac tumors can cause obstruction, valvular regurgitation, embolization, direction invations (heart block, arrhythmias, pericardial effusions, tamponade, and impared contractility), and lung invasion symptoms.

Metastatic tumors to the right ventricle are:

Renal Cell Carcinoma
Hepatocellular Carcinoma
Ovarian Adenocarcinoma
Testicular Carcinoma
Myofribroblastic  Tumor
Squamous Cell Carcinoma of the Bladder
Thyroid Papillary Carcinoma
Extracardiac Tumors or Pericardial Cysts
Cervical Carcinoma

Endomyocardial Fibrosis can simulate myocardial tumors.

Tumor is visualized on echocardiography examination. Paradoxical motion of the interventricular septum may be present. RVOT outlet obstruction may also occur.

Endomyocardial fibrosis usually involves the apical portion of the right or left ventricle, or both, and gradually extends into the inlet portion of the involved ventricle. In one case it simulated a right ventricular tumor and caused RVOT outlet obstruction.

The most likely diagnosis is a recurrence of the sarcoma. The most likely cause of her shortness of breath is decreased function of her right ventricle.
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Web Links/References
Echocardiography of right ventricular tumors
Cardiac Metastasis of an Ovarian Adenocarcinoma Diagnosed by two Dimensional Echocardiography: A Case Report and Review of the Literature on Cardiac Masses Diagnosed by Cardiac Ultrasounds
Echocardiographic Diagnosis of a Right Ventricular Metastatic Tumor
Right Ventricular Tumor and Thrombus
Right Ventricular Inflammatory Myofibroblastic Tumor
Primary right ventricular tumor (fibroma) simulating cyanotic heart disease in a newborn.
Endomyocardial Fibrosis Mimicking Right Ventricular Tumor
Right Ventricular (RV) Tumor 2D and 3D TTE - 3D Echocardiography
Paradoxical Septal Motion Secondary to Right Ventricular Tumor
Surgical excision of right ventricular carcinoid tumor in a symptomatic patient without carcinoid valve disease
Cardiac tumors
A Rare Case of Squamous Cell Carcinoma of the Bladder Presenting as a Metastatic Right Ventricular Mass
Right ventricular tumor in a patient with melanoma
Metastatic Cardiac Papillary Carcinoma Originating From the Thyroid in Both Ventricles With a Mobile Right Ventricular Pedunculated Tumor.
Isolated right ventricular metastasis of uterine cervical carcinoma
Intracardiac Metastasis of Esophageal Squamous Cell Carcinoma
[Primary lymphoma of the heart: difficulties in diagnosis and treatment].
Successful radiation treatment of anaplastic thyroid carcinoma metastatic to the right cardiac atrium and ventricle in a pacemaker-dependent patient.
Right ventricular metastasis of transitional cell carcinoma of the renal pelvis: successful single stage surgical treatment.
Right ventricular exclusion for hepatocellular carcinoma metastatic to the heart.
Intra-cardiac metastasis from testicular non-seminoma germ cell tumour; to resect or not to resect.
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