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T1 and T2 mapping for tissue characterization of cardiac myxoma
International Journal of Cardiology 169 (2013) e17–e20
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
T1 and T2 mapping for tissue characterization of cardiac myxoma Dorothee Kübler a, Michael Gräfe a, Bernhard Schnackenburg b, Christoph Knosalla c, Katharina Wassilew d, Jan-Hendrik Hassel a, Ekaterina Ivanitzkaja c, Daniel Messroghli a, Eckart Fleck a, Sebastian Kelle a,⁎ a
Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Germany Philips Healthcare, Hamburg, Germany Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Germany d Division of Cardiac Pathology, Deutsches Herzzentrum Berlin, Germany b c
a r t i c l e
i n f o
Article history: Received 12 August 2013 Accepted 29 August 2013 Available online 8 September 2013 Keywords: Myxoma Cardiac MRI CMR T1mapping T2mapping ECV
A 42-year-old woman presented to our cardiology outpatient department for evaluation of three episodes of self-limiting palpitations at rest during night time. Heart rate measured by the patient at the time of symptoms was 160 bpm. The patient reported a history of eclampsia and a five-year history of diagnosed but untreated sinus tachycardia. Physical examination showed no pathological findings. On the 24 h Holter electrocardiogram we saw sinus tachycardia (mean heart rate = 95 bpm) and multiple atrial and ventricular extrasystoles. The patient's transthoracic echocardiogram revealed a round mass in the left atrium attached to the interatrial septum (IAS, Fig. 1A). This finding was confirmed by 3D transoesophageal echocardiography (Fig. 1B) showing an inhomogeneous tissue pattern of the mass. An additional CT scan of the thorax was performed and confirmed the anatomic results from echo and CMR. No calcified areas could be detected and the mass showed partial enhancement after application of the contrast agent as shown in Fig. 1C and D. Subsequent cardiovascular MRI (CMR) for further tissue characterization performed on a 1.5 T scanner (Philips Achieva) demonstrated a ⁎ Corresponding author at: German Heart Institute Berlin, Department of Internal Medicine/Cardiology, Augustenburger Platz 1, 13353 Berlin, Germany. Tel.: +49 30 45932400; fax: +49 30 45932500. E-mail address: [email protected] (S. Kelle).
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.08.116
round mobile tumor attached to the IAS measuring 20 mm in diameter with no evidence of infiltrative growth (Fig. 2A). Compared to the left ventricular myocardium, the tissue was isointense in T1-weighted and hyperintense in T2-weighted images suggesting a high water content (Fig. 2 B; C; E; F). In addition, T2 mapping of the LV myocardium in comparison to the mass in the left atrium revealed values of 128 ± 31 msec and 47 ± 4 msec, respectively, suggesting a high water content in the mass. The region of high T2 values inside the mass demonstrated equal T2 values to the blood in the heart cavities (209 ± 34 msec) (Fig. 2D). First-pass perfusion of the mass was inhomogeneous and delayed compared to that of the left ventricular myocardium indicating no direct perfusion via the coronary arteries (Fig. 2G–H). Cardiac T1 mapping (Fig. 2J–K) revealed different T1 of the myocardium and the left atrial tumor. The extracellular volume (ECV) measurements in the myocardium and the mass demonstrated values of 29% and 59%, respectively, indicating a relevant tissue difference between the myocardium and the left atrial mass. We started treatment with a new oral anticoagulant to prevent embolic events and a beta blocker to control the tachycardia. X-ray coronary angiography was performed in order to rule out additional coronary artery disease prior to surgery, and no additional perfusion of the tumor was seen that would suggest malignancy. The patient underwent open-heart surgery with successful excision of the entire mass and subsequent reconstruction of the IAS with autologous pericardium (Fig. 3A–C). Recovery was uneventful. Histopathological examination showed a well circumscribed oval mass with a hemorrhagic and gelatinous cut surface, composed of scattered stellate cells without significant nuclear atypia, which accumulate around vessels, set in a well vascularized myxoid and fibrous stroma. There are no areas of necrosis present (Fig. 3E–F). This case demonstrates how the integration of new imaging techniques can contribute to comprehensive tissue characterization. Due to its physical properties, CMR provides superior soft-tissue contrast and therefore enables better tissue characterization than echocardiography or computed tomography alone, especially when applying new T1 and T2 mapping sequences. In addition, follow-up exams can be performed without exposure to radiation, which is of particular importance for young female patients. The diagnostic and prognostic value of such a comprehensive CMR protocol including T1 and T2 mapping warrants further investigation in large patient populations.
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D. Kübler et al. / International Journal of Cardiology 169 (2013) e17–e20
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Fig. 1. A. Transthoracic echocardiography (TTE) with magnification of the left atrial mass in the four-chamber view. Please note the area of low echogenicity (arrowhead) adjacent to the interatrial septum (IAS). B. Transesophageal 3D-echocardiography of the inhomogeneous round left atrial mass attached to the IAS measuring 1.61 cm × 1.66 cm. CT scans of C the four-chamber view and D the three-chamber view with enhancement of contrast agent (arrowhead) in the area of the mass that appeared echopenic in the TEE images of the figure. No calcified areas are detected.
D. Kübler et al. / International Journal of Cardiology 169 (2013) e17–e20
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Fig. 2. Cardiovascular MRI (CMR) showing the left atrial mass (arrowheads). A. SSFP 4-chamber-cine. B and C. T1-weighted images without and with fat suppression. D. colored T2 map. Tissue of the mass (black arrowheads): 128 ± 31 msec, region inside the mass (white arrowhead): 209 ± 34 msec corresponding to the values of blood in the heart cavities. E and F. T2-weighted images without and with fat suppression. G. First pass perfusion CMR. The left atrial mass shows no signs of blood flow as indicated by low signal during the entire first pass of contrast agent. H. Second pass perfusion showing a localized area of contrast enhancement inside the left atrial mass. I. Late Gadolinium Enhancement (LGE) inversion recovery sequence. J. T1-weighted GRE pre contrast administration. K. Colored T1 map showing different values inside the mass. L. Inversion recovery gradient-echo sequence showing the inhomogeneous tissue pattern of the mass.
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Fig. 3. A. Surgical field at the time of resection of the left atrial mass (arrowhead) with parts of the IAS measuring 1.5 × 2 cm and weighing 4.2 g that was subsequently reconstructed with a patch of autologous myocardium. B. Macroscopical appearance of the smooth surfaced resected mass. C. Cut surface of the mass with old and recent hemorrhages and cystic changes in the central portion. Histopathology, low magnification. D. Hematoxylin/eosin stained section shows the attachment of the tumor to the endocardium with areas of hemorrhage (red) and cystic change within the tumor mass subendocardially. E. Elastica van Gieson highlights the fibrous stroma in brown. F. Alcian blue stain highlights myxoid matrix in blue.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
T1 and T2 mapping for tissue characterization of cardiac myxoma Dorothee Kübler a, Michael Gräfe a, Bernhard Schnackenburg b, Christoph Knosalla c, Katharina Wassilew d, Jan-Hendrik Hassel a, Ekaterina Ivanitzkaja c, Daniel Messroghli a, Eckart Fleck a, Sebastian Kelle a,⁎ a
Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Germany Philips Healthcare, Hamburg, Germany Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Germany d Division of Cardiac Pathology, Deutsches Herzzentrum Berlin, Germany b c
a r t i c l e
i n f o
Article history: Received 12 August 2013 Accepted 29 August 2013 Available online 8 September 2013 Keywords: Myxoma Cardiac MRI CMR T1mapping T2mapping ECV
A 42-year-old woman presented to our cardiology outpatient department for evaluation of three episodes of self-limiting palpitations at rest during night time. Heart rate measured by the patient at the time of symptoms was 160 bpm. The patient reported a history of eclampsia and a five-year history of diagnosed but untreated sinus tachycardia. Physical examination showed no pathological findings. On the 24 h Holter electrocardiogram we saw sinus tachycardia (mean heart rate = 95 bpm) and multiple atrial and ventricular extrasystoles. The patient's transthoracic echocardiogram revealed a round mass in the left atrium attached to the interatrial septum (IAS, Fig. 1A). This finding was confirmed by 3D transoesophageal echocardiography (Fig. 1B) showing an inhomogeneous tissue pattern of the mass. An additional CT scan of the thorax was performed and confirmed the anatomic results from echo and CMR. No calcified areas could be detected and the mass showed partial enhancement after application of the contrast agent as shown in Fig. 1C and D. Subsequent cardiovascular MRI (CMR) for further tissue characterization performed on a 1.5 T scanner (Philips Achieva) demonstrated a ⁎ Corresponding author at: German Heart Institute Berlin, Department of Internal Medicine/Cardiology, Augustenburger Platz 1, 13353 Berlin, Germany. Tel.: +49 30 45932400; fax: +49 30 45932500. E-mail address: [email protected] (S. Kelle).
0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.08.116
round mobile tumor attached to the IAS measuring 20 mm in diameter with no evidence of infiltrative growth (Fig. 2A). Compared to the left ventricular myocardium, the tissue was isointense in T1-weighted and hyperintense in T2-weighted images suggesting a high water content (Fig. 2 B; C; E; F). In addition, T2 mapping of the LV myocardium in comparison to the mass in the left atrium revealed values of 128 ± 31 msec and 47 ± 4 msec, respectively, suggesting a high water content in the mass. The region of high T2 values inside the mass demonstrated equal T2 values to the blood in the heart cavities (209 ± 34 msec) (Fig. 2D). First-pass perfusion of the mass was inhomogeneous and delayed compared to that of the left ventricular myocardium indicating no direct perfusion via the coronary arteries (Fig. 2G–H). Cardiac T1 mapping (Fig. 2J–K) revealed different T1 of the myocardium and the left atrial tumor. The extracellular volume (ECV) measurements in the myocardium and the mass demonstrated values of 29% and 59%, respectively, indicating a relevant tissue difference between the myocardium and the left atrial mass. We started treatment with a new oral anticoagulant to prevent embolic events and a beta blocker to control the tachycardia. X-ray coronary angiography was performed in order to rule out additional coronary artery disease prior to surgery, and no additional perfusion of the tumor was seen that would suggest malignancy. The patient underwent open-heart surgery with successful excision of the entire mass and subsequent reconstruction of the IAS with autologous pericardium (Fig. 3A–C). Recovery was uneventful. Histopathological examination showed a well circumscribed oval mass with a hemorrhagic and gelatinous cut surface, composed of scattered stellate cells without significant nuclear atypia, which accumulate around vessels, set in a well vascularized myxoid and fibrous stroma. There are no areas of necrosis present (Fig. 3E–F). This case demonstrates how the integration of new imaging techniques can contribute to comprehensive tissue characterization. Due to its physical properties, CMR provides superior soft-tissue contrast and therefore enables better tissue characterization than echocardiography or computed tomography alone, especially when applying new T1 and T2 mapping sequences. In addition, follow-up exams can be performed without exposure to radiation, which is of particular importance for young female patients. The diagnostic and prognostic value of such a comprehensive CMR protocol including T1 and T2 mapping warrants further investigation in large patient populations.
e18
D. Kübler et al. / International Journal of Cardiology 169 (2013) e17–e20
A
B LV LA
RA
C
LA
D
Fig. 1. A. Transthoracic echocardiography (TTE) with magnification of the left atrial mass in the four-chamber view. Please note the area of low echogenicity (arrowhead) adjacent to the interatrial septum (IAS). B. Transesophageal 3D-echocardiography of the inhomogeneous round left atrial mass attached to the IAS measuring 1.61 cm × 1.66 cm. CT scans of C the four-chamber view and D the three-chamber view with enhancement of contrast agent (arrowhead) in the area of the mass that appeared echopenic in the TEE images of the figure. No calcified areas are detected.
D. Kübler et al. / International Journal of Cardiology 169 (2013) e17–e20
A
B
C
D
E
F
G
H
I
J
K
L
e19
RV LV
RA
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Fig. 2. Cardiovascular MRI (CMR) showing the left atrial mass (arrowheads). A. SSFP 4-chamber-cine. B and C. T1-weighted images without and with fat suppression. D. colored T2 map. Tissue of the mass (black arrowheads): 128 ± 31 msec, region inside the mass (white arrowhead): 209 ± 34 msec corresponding to the values of blood in the heart cavities. E and F. T2-weighted images without and with fat suppression. G. First pass perfusion CMR. The left atrial mass shows no signs of blood flow as indicated by low signal during the entire first pass of contrast agent. H. Second pass perfusion showing a localized area of contrast enhancement inside the left atrial mass. I. Late Gadolinium Enhancement (LGE) inversion recovery sequence. J. T1-weighted GRE pre contrast administration. K. Colored T1 map showing different values inside the mass. L. Inversion recovery gradient-echo sequence showing the inhomogeneous tissue pattern of the mass.
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D. Kübler et al. / International Journal of Cardiology 169 (2013) e17–e20
A
B
C
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20
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Fig. 3. A. Surgical field at the time of resection of the left atrial mass (arrowhead) with parts of the IAS measuring 1.5 × 2 cm and weighing 4.2 g that was subsequently reconstructed with a patch of autologous myocardium. B. Macroscopical appearance of the smooth surfaced resected mass. C. Cut surface of the mass with old and recent hemorrhages and cystic changes in the central portion. Histopathology, low magnification. D. Hematoxylin/eosin stained section shows the attachment of the tumor to the endocardium with areas of hemorrhage (red) and cystic change within the tumor mass subendocardially. E. Elastica van Gieson highlights the fibrous stroma in brown. F. Alcian blue stain highlights myxoid matrix in blue.