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Highlights When a new left atrial mass is encountered following open-heart surgery, it is important to be aware of the possibility of a left atrial invagination prior to resorting to drastic measures especially in the critical period after separation from cardiopulmonary bypass. Intraoperative transesophageal echocardiography is of immense value and the mass has to be evaluated in multiple views before arriving at a definitive diagnosis.

Primary hemangioma of the mediastinum is extremely rare. Herein, we present a unique case of hemangioma mimicking left atrial mass in the posterior mediastinum. We reviewed the literature and found 17 other hemangiomas in the posterior mediastinum. Herein, we summarize the age, gender, symptoms, diagnostic methods, image diagnosis, size, treatments, histologic features, outcomes, and follow-up of 17 cases. Most of the cases were asymptomatic and were accidentally detected in chest radiographs. Diagnostic methods mainly included chest X-ray, computed tomography (CT), and magnetic resonance imaging (MRI). All patients underwent surgical resection, recovered well, and had no recurrence during follow-up.

Left atrial (LA) mass of >60 mm length is rarely detected on echocardiography. Large LA masses like this are often complicated by embolic phenomenon and if early surgical intervention is not done, clinical course can be devastating. We report a case of large LA mass with multisite embolization leading to fatal multi-organ failure.

Anti-phospholipid antibody syndrome (APS) has a broad spectrum of thrombotic and nonthrombotic clinical manifestations. The diagnosis requires a set of clinical criteria of thrombosis along with persistently positive anti-phospholipid antibody tests. In this report, we are presenting a case of APS, who is a 38-year-old male, presented with complains of seizures and found to have stroke, which on further investigation revealed to have been caused possibly from a left atrial mass. Therefore, high index of suspicion is required for the diagnosis of APS in young patients, who present with various neurological and cardiovascular manifestations, mostly secondary to thrombosis.

Focused Intensive Care Echo can aid diagnosis in complex patients where initial investigations are non‐diagnostic. FICE is an essential skill for critical care physicians, and bedside echocardiography should be a standard investigation for all critical care patients., FICE can aid diagnosis in complex patients where initial investigations are non‐diagnostic. FICE is an essential skill for critical care physicians, and bedside echocardiography should be a standard investigation for all critical care patients.

Sentinel cerebral embolic protection devices (CPDs) may limit periprocedural cerebrovascular events by preventing micro and macro-embolization to the brain, and has been used in many cardiology and radiology procedures. We hereby report the use of a Sentinel CPD to facilitate safe and effective atrial fibrillation ablation in a patient with a left atrial mass arising from the interatrial septum.

Coronary artery fistula are anomalous connections with coronary vessels or cardiac chambers, potentially resulting in coronary dilatation and pseudoaneurysm formation. We present the case of a 68-year-old woman referred to our institution for a voluminous coronary pseudoaneurysm secondary to coronary artery fistula presenting as a nearly completely obstructive left atrial mass. (Level of Difficulty: Intermediate.), Central Illustration

Background Intimal sarcoma is an exceedingly rare type of primary cardiac tumour. It is characterized by poorly differentiated spindle-shaped cells that can mimic smooth muscle and is strongly associated with MDM2 genetic amplification. Owing to its rarity and non-distinctive histological features, diagnosis remains a significant challenge. Case summary In this case report, we describe a case of primary cardiac intimal sarcoma in a 37-year-old woman who presented with atrial fibrillation (AF) and a left atrial mass. Despite having a histological sample from an excised left atrial mass, the diagnosis was not made until she presented with back pain secondary to metastatic disease to the spine. Discussion Primary cardiac intimal sarcoma is an extremely rare diagnosis. The mainstay management of intimal cardiac sarcoma is aggressive surgical resection. Unfortunately, the prognosis of cardiac sarcomas remains very poor, with a mean survival between 3 months and 1 year. This case of cardiac intimal sarcoma highlights the difficulty in establishing a diagnosis, particularly given the unusual presentation of AF.

Rhabdomyoma in the absence of tuberous sclerosis presenting as a large solitary atrial mass is an atypical finding. We hereby present images from an infant with a fetally diagnosed large left atrial mass with no evidence of mitral valve dysfunction who subsequently developed persistent arrhythmias requiring surgical resection of the mass in the neonatal period.

Intramyocardial hematomas are a rare complication of myocardial infarctions. Normally restricted to the left ventricle, in certain scenarios, such as after a percutaneous coronary intervention, intramyocardial hematomas also can occur in the left atrium. Herein, the case of a 74-year-old man who presented to the authors’ institution with a large inferior wall myocardial infarction refractory to multiple pressor therapy and thus necessitated venoarterial extracorporeal membrane oxygenation support is described. Through the course of his hospital stay, the patient developed a large left atrial intramyocardial hematoma obstructing mitral inflow as seen on intraoperative transesophageal echocardiography. Ultimately, because of the patient's complex comorbid status, his case was managed conservatively. In this E-challenge, the reason for the conservative approach and the alternative approach of surgically draining the intramyocardial hematoma are discussed.

Graphical abstract, Highlights • LAIH may be a complication of blunt chest trauma. • Multimodality imaging with TEE and CMR can lead to the correct diagnosis. • Conservative management may be considered in hemodynamically stable patients.

Cardiac angiosarcoma is the most common among primary malignant cardiac tumors in adults. Malignant cardiac tumors commonly arise in the right-sided cardiac chambers unlike benign tumors that commonly arise in the left-sided chambers. Cardiac tumors on the left side need to be carefully assessed for malignant features for deciding treatment strategy and prognostication. We present the case of a 62-year-old female with a large left atrial mass infiltrating the interatrial septum and adjacent myocardial wall. Histology was suggestive of angiosarcoma. Although a radical excision was done, the tumor recurred within 6 months of the postoperative period and she died shortly after the recurrence.

Left atrial Intramural hematoma (LAIH) is rare complication cardiac invasive procedures. The article analyses the mechanism of formation of this pathology. The case of the LAIH after percutaneous coronary intervention (PCI) is presented. The patient complained of intensive chest pain. When performing ECHO, LAIH was found. LAIH occupied a large part of the cavity left atrium. The conservative supervision of the patient was chosen despite the compession of the left inferior pulmonary vein and symptoms of the acute heart failure. The successful symptomatic treatment was conducted. Taking into consideration the recent PCI dual antiplatelet therapy was not interrupted. LAIH gradually regressed. Five weeks after the desease began, the patient was discharged from the hospital. Nine months after almost full lysis of LAIH was observed. The discussion section is devoted to the issues of diagnosis, the choice of medical tactics, the necessity of surgical treatment and the stop of antitrombotic theatment.

Graphical abstract, Highlights • Echocardiography is useful in differentiating intracardiac masses. • Cardiac thrombus may be mistaken for atrial myxomas by echocardiography. • Echocardiographic contrast can aid in the diagnosis of atrial thrombus.

Summary Fibroelastomas are rare, primary cardiac tumours with a predilection for valvular endothelium and a propensity to embolise. We present the case of a 72-year-old male with multiple cerebrovascular events (CVA) despite oral anticoagulation. Transoesophageal echocardiography (TOE) revealed a small highly mobile left atrial mass with frond-like projections attached by a stalk to the orifice of the LAA. The mass was surgically excised and confirmed to be a fibroelastoma on histological examination. This case report describes a rare but treatable source of multiple cerebrovascular events and highlights the utility of TOE in the assessment of cardiac embolic source. Learning points: Fibroelastomas are most commonly found on left-sided heart valves (aortic > mitral) and have the potential to cause systemic emboli associated with significant morbidity and mortality. A left atrial appendage (LAA) mass in a patient presenting with cerebrovascular events does not always represent thrombus. Uncommon aetiologies such as a cardiac tumour should be considered in the differential diagnosis. Transthoracic echocardiography (TTE) does not provide an accurate assessment of the LAA and should not be used to detect pathology within this structure. Transoesophageal echocardiography (TOE) is superior to TTE in imaging the LAA and provides a complete delineation of its anatomy. In addition, TOE can detect very small highly mobile lesions (as described in this case), which may be missed on other imaging modalities.

Antiphospholipid antibody syndrome (APS) has a broad spectrum of thrombotic and non-thrombotic clinical manifestations. Diagnosis requires a set of clinical criteria of thrombosis along with persistently positive anti-phospholipid antibody tests. In this report, we are presenting a case of APS, who is a 38 years old male, presented with complains of seizures and found to have stroke, which on further investigation revealed to have been caused possibly from a left atrial mass. High index of suspicion is required for the diagnosis of APS in young patients, who present with various neurological and cardiovascular manifestations, mostly secondary to thrombosis. APS usually is classified as primary and secondary, respectively, according to the absence or presence of an underlying disease as well as other autoimmune, malignancy, or drug-induced disorders.

Background Cardiac foreign bodies (FBs) are rare findings that may present as cardiac masses initially. Here, we present an exceptional and rare case of a hypodermic needle FB that transmigrated to the left atrium and presented as a left atrial mass. Case summary A 28-year-old woman with multiple psychiatric disorders including intentional FB ingestion and self-inflicting injuries presented to the emergency room with abdominal pain, nausea, vomiting, diarrhoea, and chest pain that radiated to the left arm and face for 2 weeks. An echocardiogram was performed revealing a left atrial mass concerning for myxoma. During the surgical removal of the mass, a hypodermic needle was found attached to the roof of the left atrium surrounded by thrombotic and fibrotic tissue, which was confirmed by pathology. Discussion Cardiac FBs are caused generally by penetrating wounds from direct trauma. Fewer cases have been reported regarding cardiac FB caused by ingestion from migration of the object to the heart. Signs and symptoms for cardiac FB may mimic those of cardiac masses. Cardiac FBs often require surgical intervention to avoid complications.

Graphical abstract, Highlights • Primary mitral regurgitation should be further evaluated with TEE. • Incidental cardiac mass on TEE is better characterized with cardiac magnetic resonance. • Cardiac tumors can affect the mitral valve.

Left atrial mass after excision of a left atrial myxoma may occur due to residual or additional masses, such as biatrial or multicentric myxomas and inverted left atrial appendage. In this E-challenge, the authors present a case where intraoperative transesophageal echocardiography allowed visualization of a left atrial mass after excision of a left atrial myxoma. Detailed examination demonstrated that the mass was due to left atrial dissection that progressed to rupture, allowing its early detection and repair. A high index of suspicion, as well as coordination between the surgeon and the perioperative echocardiographer, played a crucial role in the detection and management of this complication.

Graphical abstract, Highlights • Spindle cell sarcoma is rare and may remain silent until advanced. • Symptoms include obstruction, local invasion, embolism, and sudden cardiac death. • It is a highly aggressive tumor and can metastasize quickly. • Overall prognosis is poor, with a mean survival of 3 months to 1 year. • Several imaging modalities are used, including echocardiography, CT, and cardiac MRI.

Cardiac masses can be caused by various etiologies [(1)][1]. Current practice relies on imaging to characterize masses without providing a definitive diagnosis, which is often made after surgical resection. In some cases, it would be prudent to have a definitive diagnosis before subjecting the

A 40 year-old athletic woman presented with worsening dyspnea on exertion over the preceding several months. Chest radiograph showed borderline cardiomegaly and subsequent echocardiography demonstrated a 5.0-cm left atrial mass as well as left-to-right interatrial shunting through a patent foramen ovale. Cardiac magnetic resonance imaging was performed, which demonstrated signal characteristics consistent with an atrial myxoma. The patient then underwent urgent surgical treatment with good technical and clinical outcome. Histologic examination confirmed an atrial myxoma. Cardiac magnetic resonance imaging was valuable in characterizing the nature of the atrial mass and patent foramen ovale, helping guide the surgical approach.

Mobile masses within the left atrial cavity are commonly caused by organized thrombi or left atrial myxoma. The use of transesophageal echocardiography has provided means for differentiation between the two conditions. We report a case of a left atrial mass in a middle age male patient having past history of closed mitral commissuro to my presented with mitral stenosis and atrial fibrillation. On transthoracic echocardiography (TTE) a round mass appeared freely mobile in left atrium but did not prolapse between the mitral leaflets due to the tightly stenosed valve orifice. In the presence of mitral stenosis, atrial fibrillation and dilated left atrium, the appearance of the mass was like mobile thrombus but possibility of left atrial myxoma cannot be ignored. Consequently, the patient was referred for surgical treatment and the mass removed through left atriotomy. Microscopic examination revealed a highly organized thrombus. We conclude that TTE is still a reliable tool in the diagnosis of large mobile atrial thrombi; TEE may help for differentiate clot from atrial myxoma but histopathological examination is a gold standard. Key words: left atrium, mitral stenosis, mitral valve replacement, CMC-closed mitral, commissurotomy.

The differential diagnosis of a left atrial mass on echocardiogram includes thrombus, vegetation, tumour, and other rare causes like septal aneurysm, pulmonary vein remnant, and septal haematoma. We present interesting echocardiographic images of a rare condition which can masquerade as a left atrial mass following cardiac surgery.

Cardiac myxoma is the most common type of primary cardiac neoplasm. Over 70% of all cardiac myxomas originate from the left atrium (LA) and 18% from the right atrium (RA). Most myxomas present with constitutional, embolic, and obstructive manifestations. We are presenting a case where a part of myxoma got embolized intra-operatively. Using trans-oesophageal echocardiography, we were able to diagnose and image the transit of the tumor from the left ventricle to the left atrium. We removed the embolized tumor from the left atrium and prevented a dreaded complication like stroke, mesenteric ischemia, renal infarct or limb ischemia, which would have resulted in increased morbidity or mortality of the patient.

Today, left atrial dissection is described as a rare complication of cardiac surgery, particularly after a mitral valve replacement. We report a rare case of left subacute atrial dissection occurred as a result of a domestic accidental fall. Transesophageal echocardiogram, angio-computed tomography, and magnetic resonance imaging showed an intramural formation with clear margins and a seamless cleavage with the posterolateral wall of the left atrium, which determined an obstacle to the ventricular filling. The patient was then operated in order to empty the hematoma and reattach the atrial wall.

Background Cardiac myxomas are the most common benign primary cardiac tumours. The natural history of left cardiac myxomas is thought to be of slowly growing tumours. Cardiac myxomas are a heterogeneous group with a variable growth rate. They present usually with stroke, valve obstruction, or non-specific symptoms. Surgical resection is the effective treatment. Case summary This case report describes a 56-year-old hypertensive and dyslipidaemic female, when she was admitted in January 1990, complaining of loss of appetite, aches, pains, and palpitations. Her workup included a transthoracic echocardiography and transoesophageal echocardiography, which showed a left atrial mass attached to the inter-atrial septum, highly suggestive of left atrial myxoma. She was referred for surgical removal of the left atrial mass. However, she was reluctant to undergo surgery as she felt better. The patient was followed-up for almost 30 years with the left atrial mass confirmed as left atrial myxoma by cardiac magnetic resonance imaging. The left atrial mass became smaller in size and more calcified. Discussion Cardiac myxomas are a group of heterogeneous tumours, thought to be slowly growing. The growth rate of cardiac myxomas prior to diagnosis is not well known, as the vast majority is treated with surgical resection immediately after diagnosis. Our case showed the natural progression of an unoperated smooth-surfaced left atrial myxoma followed-up for almost 30 years, which slowly became smaller and more calcified.

Background. Echocardiography is an important diagnostic tool in differential diagnosis of retrosternal pain. Despite the high prevalence of hiatus hernia, a relatively small number of echocardiographically manifested cases have been reported. Case summary. A 75 y old female patient with rheumatic polymialgia and diabetes was admitted for progressive weakness, retrosternal pain and dyspnoea. Due to elevated levels of D-dimer and troponin I an urgent CT angiography was performed and a diagnosis of pulmonary embolism was confirmed in the ER. Echocardiography showed a mildly hypertrophied left ventricle with normal EF, a mildly dilated right ventricle, moderate pulmonary hypertension 45 mmHg, and an apparent mass in the left atrium (picture). To further characterize the left atrial mass a cardiac MR angiography was made, that excluded potential cardiac tumor and confirmed that the suspected mass was a large hiatus hernia impressing the left atrium. Patient was treated with anticoagulant therapy due to PE and corticosteroids due to polymialgia and was discharged in improved condition. We also consulted thoracic surgeons regarding hernia and did not decide to operate on the hernia urgently but opted for conservative reflux measures and an outpatient follow up with barium contrast oesophagus imaging. Discussion. Hiatal hernia may exert a wide spectrum of manifestations mimicking acute cardiovascular events, from ECG changes to angina, dyspnoea and even syncope as a consequence of total compression of the left atrium. A history of known hiatus hernia and aforementioned clinical correlates postprandially may shed some clues. Echocardiographic features that may suggest a hiatus hernia include: 1. A large ill-defined mass filling the left atrial chamber from posteriorly, with its maximal size seen when imaged in a posterior plane. 2. Respiratory variation in the degree of encroachment of the mass on the left atrium. 3. Loss of the normal sharply defined sonolucency of the descending thoracic aorta in the apical 4-chamber and long-axis views due to superimposition of the hiatus hernia. 4. A swirling motion seen within the mass after consumption of effervescent fluids. 5. Occasionaly, identification of an inner lining reminiscent of gastric mucosa is possible. Various intracardiac or extrinsic lesions can resemble the echocardiographic appearance of hiatus hernia. Other potential causes of extracardiac masses that could encroach on the left atrium include structures such as aneurysm or dissection of the aorta, dilation of coronary sinus, abcesses, oesophageal carcinoma and other mediastinal space occupying structures. Conclusion. Hiatus hernia can simulate clinical and sonographic characteristics of cardiac disorders. Its echocardiographic manifestation may mimic a left atrial mass and must therefore be differentiated from such lesions. Abstract P687 Figure. Hiatal hernia mimicking LA mass(PLAX)

Mesothelial/monocytic incidental cardiac excrescence (MICE) is a rare benign finding made of mesothelial cells, histiocytes, and fibrin, usually found during heart valve surgery. The clinical relevance resides in the potential misdiagnosis as metastatic carcinoma or arterial embolism. The pathogenesis remains uncertain, with artifactual and reactive hypotheses. Here we present a case of MICE with paradigmatic clinical, imaging, and histological features in a 28-year-old woman with undifferentiated connective tissue disease without previous cardiac catheterization with possible pathogenesis, highlighting the importance of awareness of the existence of this lesion in patients with autoimmune disease.

Graphical abstract, Highlights • Atypical presentation of atrial mass. • Spontaneous embolization of large left atrial mass. • Near total occlusive saddle embolus of aortic bifurcation.

Cardiac mass is defined as an abnormal structure within or immediately adjacent to the heart. The three basic types of cardiac masses are tumor, thrombus, or vegetation. Echocardiography is the main diagnostic tool for the detection of a cardiac mass. We present an infant with a mass in the left atrium in whom there was a diagnostic dilemma.

Extracardiac intrapericardial masses arising posterior to left atrium (LA) often mimic an intracardiac LA mass on echocardiography. Although transthoracic echocardiography (TTE) is the primary screening tool to detect any cardiac mass, transesophageal echocardiography (TEE) is proven superior to TTE in delineating the size, morphology, and exact site of origin of LA masses. We report a case, where the preoperative TTE diagnosed an LA mass which was later confirmed to be an extracardiac intrapericardial mass by cardiac magnetic resonance imaging and intraoperative TEE. The mass was compressing the LA, and the timely diagnosis avoided the opening of the LA for mass excision.

Left atrial (LA) appendage inversion is a rare event in cardiac surgery and can often be mistaken for a mass, thrombus, or vegetation. This can be a challenge, especially in the case of a left-ventricular-assist device where a correct diagnosis is of crucial significance. Intraoperative transesophageal echocardiography is an invaluable tool to detect an inverted LA appendage and differentiate it from other potentially dangerous diagnosis like LA clot. Knowledge of this entity along with a high index of suspicion can help early diagnosis of this scenario and avoid unnecessary reinstitution of cardiopulmonary bypass and resurgery

Cardiac myxoma with glandular elements is extremely rare cardiac myxomas that show glandular differentiation, the pathogenesis of which is unknown. The present case study reports a case of glandular cardiac myxoma. A 21-years-old female presented with left atrial mass which was surgically resected and sent for histopathological examination. Microscopically, there were well formed mucinous glands in a background of cardiac myxoma and hence cardiac myxoma with glandular elements was confirmed. Though rare, it should always be differentiated from metastatic adenocarcinoma.

Les sarcomes cardiaques primitifs sont extrêmement rares et de pronostic sombre. L’existence du sarcome intimal, tumeur mésenchymateuse maligne affectant principalement l’artère pulmonaire et l’aorte, est rapportée au niveau du cœur mais reste encore débattue. Nous rapportons le cas d’un sarcome intimal développé chez une patiente de 70 ans, avec ses caractéristiques macroscopiques, microscopiques et moléculaires. [Cardiac intimal sarcoma: A case report of a rare tumor with peculiar histopathological findings] Primary cardiac sarcomas are rare tumors with poor prognosis. Intimal sarcoma, a mesenchymal malignant tumor described mainly in the great vessels, may rarely involve the heart. Herein we describe the case of a 70-years-old female who was found to have a left atrial mass during an investigation of a new onset dyspnea. The patient underwent surgery and the resected mass was found to be an intimal sarcoma. The objectives of this report were to describe a case of this rare disease entity and to discuss its pathological and molecular findings based on relevant literature.

Cardiac myxomas are rare with reported incidences of less than 0.03%. Cardiac myxomas are most commonly observed in the left atrium. Their clinical manifestations vary and most are non-specific to the diagnosis. The most common extra-cardiac manifestations are thrombo-embolic infarcts from tumor embolization. A previously healthy 55-year-old man presented with findings suggestive of acute arterial limb ischemia. Following surgical treatment of his acute presentation, a left atrial mass was found on echocardiography suggesting that the embolization was secondary to a cardiac myxoma. The patient was discharged without complication. Embolic myxoma should be included in the differential in younger, previously healthy patients presenting with acute arterial limb ischemia without obvious cause. Our patient’s dramatic presentation with a single acute event, however, prompted immediate treatment and resulted in a functional recovery with minimal complications.

Introduction Myxoma is the most common cardiac benign tumour. While a typical myxoma is generally a straightforward diagnosis, some myxomas have unusual features that can make the diagnosis challenging. Glandular myxomas and metastatic adenocarcinomas, the most common type of metastatic carcinoma to the heart, can have very similar features. Case presentation We report a 60-year old man who presented with progressive shortness of breath on exertion. Echocardiography demonstrated a large heterogeneous, cystic left and right atrial mass. He was referred for surgery where a smooth and multilobulated left atrial mass was excised. Histopathological analysis with special stains revealed an unusual form of cardiac myxoma with extensive glandular differentiation. Discussion Cardiac myxomas can present with diverse clinical, radiological, and pathological features. Echocardiography is a modality of choice for diagnosis but can also miss small or multiple masses. Cardiac myxoma with glandular features is a rare type of myxoma. In our case, there was extensive glandular differentiation and the echocardiographic appearance provided clues for the unusual features of the tumour, suggesting a potential role for echocardiography in the detection and recognition of this morphologic histologic variation.

Giant coronary artery aneurysms are exceedingly rare. Symptoms are vague and often related to myocardial ischaemia or compression of a cardiac chamber. Surgery is indicated when obstruction to the circulation results in heart failure or syncope, as in our case. A clear elucidation of the pathology may not be possible before exploration and the surgical strategy is tailored to the individual case.

Described herein is a 71-year-old woman with previous angina pectoris who suddenly developed slurred speech and right-arm weakness. She was found to have significant coronary narrowing, a small mass in the left atrium attached to the endocardium near the orifice of the appendage, and multifocal punctate cerebral lesions in the distribution of the left middle cerebral artery. The left atrial mass was excised and confirmed to be a papillary fibroelastoma. Coronary bypass was also performed. It is believed that fibrin thrombus developed within the fronds of the fibroelastoma and embolized to the brain. Such lesions in the left atrium are exceedingly uncommon. She had no further emboli events.