Download CT for Cardiac Masses

3/7/2013
Disclosures
CT Imaging of Masses
and Cardiac Devices
Suhny Abbara, MD
Associate Professor, Harvard Medical School
Director of Education, Cardiac MRCT Program
Director Cardiovascular Imaging Fellowship,
Massachusetts General Hospital
[email protected]
• Medical Advisory Board Member
– Partners Imaging
– Perceptive Informatics
– Magellan Healthcare
• Consultant / Editing / Authoring (honoraria):
– EZEM
– Siemens Medical Systems
– Amirsys, Inc.
• Research Funding
– Bracco
Iodinated contrast not FDA approved for coronary CTA
Role of cardiac CT
• Exclude obstructive coronary artery disease
CT for Cardiac Masses
• Characterize mass if Echocardiography and
MRI not diagnostics / contraindicated
– Fat, soft-tissue, calcium component
– Enhancement (inferior to MRI)
– Coronary artery involvement
• Recognize undiagnosed incidental masses
Imaging Masses with CT
• Protocols depend on specific clinical question
and type of mass
• Low dose pre and delayed phase scans ad
valuable information
• Right atrial / RV masses require specific right
heart injection protocols
• Failure to evaluate large Field of View malpractice
CT DDX for Masses is based on:
• Definitive Signs of Malignancy
– Invasion, metastatic disease
• Single vs. Multiple Lesions
• Location of Epicenter
– Chamber, intraluminal, intramyocardial, epicardial,
pericardial, extracardiac
– More than one tissue type involved?
• Presence of Calcification
• Presence of Fat
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Cardiac Lipoma
Masses containing
Fat
Oyama, Circulation 2003;107:e200
Lipomatous Hypertrophy of Atrial
septum
Lipomatous Hypertrophy of Atrial
Septum
Consists of Brown Fat
May be hot on FDG PET
Lipomatous Hypertrophy of Atrial
Septum
11
Fan, Fischman, Kwek, Abbara, Aquino. AJR 2005
184(1):339-42.
Lipomatous Hypertrophy of Atrial
Septum
12
Fan, Fischman, Kwek, Abbara, Aquino. AJR 2005 184(1):33942.
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Cardiac (Pericardial) Teratoma
Pericaval fat invaginating into IVC
First described
in 1997 (Han BK, et
Raju, Austin. Radiology
2001
al. Radiology)
May mimic
tumor thrombus
• Rare
• Contains tissue from all 3 germ cell layers:
– Calcium, Teeth, Hair, Fat
Morgagni Hernia
Multiple Cardiac Lipomas
Extracardiac or rarely intrapericardial mass
Connects to abdomen via Morgagni triangle
May contain omental fat, bowel, stomach or
liver
*
Tuberous Sclerosis
*
Other Fat Containing Cardiac Lesions
• Fatty metaplasia due to
remote myocardial infarction (MI)
• Arrhythmogenic RV
Dysplasia (ARVD)
• Liposarcoma
– May not contain
macroscopic fat!
Masses containing
Calcium
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Fibroma = Fibrous Hamartoma
• Low Grade, heterogeneous enhancement
• Coarse calcifications
Fibroma = Fibrous Hamartoma
• Large solitary noncontractile mass
• 50% have coarse
calcifications
• Benign congenital cardiac
neoplasm composed of
collagen and fibroblasts
Green D. Fibroma. (Image Courtesy C. White)
In: Abbara S, Walker G. DI Cardiovascular. Amirsys Inc. 2008
Atrial Osteosarcoma
Caseous MAC
• MAC is common (most women > 60)
• Caseous MAC is rare: 0.6% of all MAC (Harpaz, JASE 2001)
• Typically: large bean-shaped mass with calcified rim and
central lower attenuation (but calcified on NECT)
Courtesy Dr. Shawn Teague
Caseous MAC
Vanovermeire et. al., IJCI
2006
Caseous MAC
Courtesy Wolfgang
Eicher, MD
Rojas CA et al. March 2010
www.mgh-cardiovascimages.org
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Angiosarcoma
Other
Malignant
Masses
Angiosarcoma
Angiosarcoma
Mimickers
Angiosarcoma
Sarcoma
Loculated Effusion
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Rhabdomyosarcoma
Chondrosarcoma Metastasis
CT
Encases RCA
Enhances
Effusion,
Invades:
Cine Fiesta 4CH MRI
T2W SA
Epicardial fat &
valves
B Desjardins, EA Kazerooni. AJR 2004; 182:993-1010
Primary Myxofibrosarcoma of Mitral Valve
Primary Pericardial/Cardiac Lymphoma
Primary Pericardial
Lymphoma
Wang ZJ, et al. Radiographics.
2003;23:S167-S180
Metastatic Disease – Extracardiac Metastases
Primary Cardiac Lymphoma
Abbara S. Cardiac Lymphoma. In: Abbara,
Walker. DI Cardiovascular. Amirsys 2008
Tumors
extendingmass
into Atria
Retroperitoneal
20-40 times more common than
primary cardiac tumors
Diagnostic clues:
• Multiple lesions
• Hemopericardium
• Extra cardiac primary/metastases
Abbara S. Cardiac Metastases.
In: Abbara S, Walker G. DI Cardiovascular. Amirsys Inc. 2008
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Masses Directly Extending into Heart
Tumor extension – Osteosarcoma Met
“Tumor Thrombi”
• IVC
– Renal, Adrenal, Hepatic, Retroperitoneal, Uterine
• SVC
– Neurogenic, Mediastinal, Lung
• Pulmonary Veins
– Lung Cancer, Metastatic Disease
Courtesy Dr.
Stephan Achenbach
Tumors extending into RA/RV
Intravenous
Leiomyomatosis
Benign
Masses
(Not Previously Mentioned)
JA Rocha-Filho et al., MGH www.mghcardiovascimages.org
PAPILLARY FIBROELASTOMA
Q1:
AFIP
archive
Abbara, Walker. DI Cardiovascular. Amirsys
Courtesy Dr. Ron Blankstein
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3/7/2013
Fibroelastoma Prolapsed into RCA
Left Atrial Myxoma - 16slice MDCT
SYSTOLE
DIASTOLE
H Medina, et al. MGH
www.mgh-cardiovascimages.org
LAA Thrombus?
Delayed Scans – Slow Filling
Cavities
• TEE is gold standard,
but can be difficult to
visualize
• CT Pitfall:
slow contrast mixing
– need delayed
phase to confirm
thrombus
Abbara S. Cardiac Masses.
In: Abbara S, Walker G. DI Cardiovascular, Amirsys 2008
LAA thrombus – persistent filling
defect
Occlusion Devices
Joshi, Abbara. Cardiology Clinics 2009.
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Amplatzer Septal Occluder
ASD Closure Device – self centered
RV
LV
LV
CA Rojas et al. Heart, subm.
CardioSEAL STARFlex Septal Occluder
ASD Closure Device – self centered
RV
Ao
LV
LV
LV
HEART VIEWS VOL. 1 NO. 7
MARCH / MAY 2000: 248-250
CA Rojas et al. Heart, subm.
PDA Closure Device
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LAA Occlusion Device (Watchman)
Successful LAA Occlusion (Watchman Device)
Barbs
Failed Watchman LAA Occlusion - 1
Failed Watchman LAA Occlusion - 2
Joshi, Blum, Mansour, Abbara. CT Applications in EP. Cardiol Clin (2009) In press.
Failed Watchman LAA Occlusion - 3
IABP
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IABP
Prosthetic Valves
Artificial Cardiac Valves
Starr Edwards
Three Pronged Aortic Silastic ball valve
• Mechanical Valves
– Ball in cage or caged ball
– Single tilting disc
– Bileaflet
• Bioprosthetic Valves
–
–
–
–
–
Strut mounted porcine xenograft
Wire mounted pericardial valve
Bovine xenograft
Cryopreserved homograft
Pulmonary autograft (Ross procedure)
Starr Edwards Valve
Titling disc valves valves
•
Bjork-Shiley (1969-1986)
–
–
–
–
•
flat disc (1969) and convexo-concave (1975) disc
Convexo-concave 2% strut fractures
prophylactic valve replacements and a class action suit
~ 300,000 Flat and ~86,000 convexo-concave implanted
Lillehei-Kaster (1970-1987)
– Two side prongs hold valve
– ~ 55,000 implanted
– newer models (Omni-Science & Omni-Carbon) still in production
•
Medtronic-Hall (previously Hall-Kaster valve, 1977)
–
–
–
–
Titanium housing, pyrolite disc
Strut traverses hole in disc
Wide spread use, > 300,000
No mechanical failures reported, still in production
Courtesy Dr. Stephan Achenbach
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Medtronic Hall Tilting Disc Valve
Abbara S. Prosthetic Cardiac Valves. DI Cardiac. Amirsys Inc. 2007
Bi-leaflet Valves
•
St. Jude Medical (1977)
– First "all carbon" valve (pyrolyte)
– 1.3 million valves implanted
•
Carbo-Medics (1986)
– ~ 500,000 implanted. Pyrolite housing and pyrolite discs
– Housing can be rotated within sewing ring
•
Gott-Daggett (1963-1966):
•
Kalke-Lillehei (1968):
– ~ 500 implanted, flexible carbon coated leaflets
– first hingeless bileaflet valve, only one implanted due to patient demise within 48
hours
•
On-X:
•
ATA open pivot valve:
– New carbon structure may allow lower anticoagulation levels (still investigational)
– Bileaflet pyrolite valve with titanium lock ring
Mechanical Heart Valves
St. Jude’s Mitral Valve Replacement
St. Judes Valve in 60yom pre PVI
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St Jude
Diastole
Systole
Stuck Valve
Normal
Thrombosed Diastole
“frozen”
Semi Disc
Systole
C Renard et al.
Journal de Radiologie
2008, 89 (11):1703-1710
Stuck Valve
Courtesy Dr. Stephan Achenbach
Dehissed AVR with large pseudoaneurysms
Courtesy Dr. Stephan Achenbach
St Jude's mitral and aortic valve replacement
Soni, Abbara. Assessment of vavlular heart disease by CT.
In: E Braunwald et al. Harrison’s Online. 2008
LV Apical-Aortic Valved Conduit
Abbara S. Apical aortic Conduit. DI Cardiovascular. Amirsys Inc. 2007
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LV Apical-Aortic Valved Conduit
LV Apical Conduit - Infection
Tissue Valves (Bioprostheses)
Bioprosthetic Valves
•
Hancock
Hancock porcine xenograft
Carpentier-Edwards
– Porcine valve mounted on Dacron covered polypropylene strut
– Glutaraldehyde preserved
•
Carpentier-Edwards porcine xenograft
– Wire mounted porcine or pericardial valve
Pressure fixed and glutaraldehyde preserved
•
Ionescu-Shiley
– Bovine xenograft
•
Cryopreserved homograft valve
•
Pulmonary autograft
3 months of anticoagulation until sewing ring becomes endothelialized
No anticoagulation thereafter
Porcine Valves
Hancock
Carpentier Edwards Bioprosthetic Valve
Carpentier-Edwards
84
Courtesy Curtis Green, MD
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Paravalvular Leak & Pulsating Pseudoaneurysms
Endocarditis
Abbara S. Prosthetic Cardiac Valves. DI Cardiac. Amirsys Inc. 2007
Bioprosthetic AVR with Pseudoaneurysm
Value of MDCT Recognized in Surgical Literature
28-year-old man w large pseudoaneurysm s. aureus endocarditis
Para-prosthetic Abscess with Pseudoaneurysm
Ao
*
Chen, Jeudy, Thorn, White. JCCT 2008 3 (1): S47-S56
S LentiniAJ
et Sharkey
al. The Annals
Thoracic
Surgery 2009, 87(5):1585-1587
et al.ofEur.
J. Cardio-thoracic
Surg. 35 (6),
pp. 1079
Endocarditis: CT vs. TEE/Surgery
37 pt’s, 28 surgeries within 5 days
Dx based on Modified Duke criteria
CT within 1 day of TEE
LA
G. Feuchtner, …, H. Alkhadi. J Am Coll Cardiol 2009;53:436–44)
G. Feuchtner, …, H. Alkhadi. J Am Coll Cardiol 2009;53:436–44)
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3/7/2013
IVC Filter Strut Fracture and Embolism
Other Medical Devices
43 yo female with hx of pain
Acupuncture Nedels
Acupuncture Needels
Thank You!
[email protected]
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