Teaching Case

Chest SCT performed for staging of esophageal cancer.Unsuspected apical left ventricular intra-cardiac mass

Patient admitted for progressive dysphagia on liquid and solid. An epidermoid tumor of the mid third portion of the esophagus was diagnosed by gastroscopy. A chest SCT was performed to assess the extent of the esophageal tumor. The SCT fortuitously discovered the presence of an intracardiac 2.5 cm mass, clearly delineated by contrast media, located at the level of the apex of the left ventricle. The wall thickness of the apical myocardium was also thin, suggesting an ancient apical infarct, complicated by a thrombus. A transthoracic echocardiography was then performed and confirmed the presence of an apical left ventricular sessile thrombi, slightly mobile, associated with an apical akinesia.

Intracardiac thrombi represent a potential risk of pulmonary embolism or cerebral stroke in accordance with the location in the right or left cardiac chambers. It is mandatory to prevent these serious complications with an efficient therapy (1). Transesophageal echocardiography (TEE) is superior to transthoracic echocardiography to diagnose intracardiac masses (2). Patent foramen or inter ventricular or auricular communication can be also rule out with these modalities. With transthoracic echocardiography, the presence of a larger left ventricular apical thrombus is easy to recognize when it protrudes. However, when the thrombus mass is smaller and has a mural extension rather than protruding, it can be more difficult to discern it and can not be easily differentiated from the apical wall. In that case its presence may be suspected based on the fact that the apex is thicker than usual (in the normal, non-infarcted situation, the apex is thinner than the rest of the myocardial wall). An advantage of the SCT seemed that it was capable of differentiating between thrombus and apical wall. Whether this is the result of better resolution of SCT or due to slightly different slice orientations between the two techniques is not clear. The main advantage of transthoracic echocardiography is that it provides real-time information of wall motion and thrombus mass, which is very helpful in detection of thrombus. Furthermore, transthoracic echocardiography is cheap, easy to perform and it does not require contrast media or X-ray burden. Multi-slice SCTs are more and more widespread and units are even located at the emergency room. With fast scanning technique, better temporal resolution and reduced motion artifacts compared to conventional SCT, moving structures like the heart are better depicted (3). With a short pregroup adapted to the heart chambers enhancement, multi-slice SCT could become a modality of choice in the evaluation and characterization of intracardiac masses. ECG gating technique, in development, will certainly improve temporal resolution even more. Mutli-slice SCT is also less invasive than TEE, and reproducible. This technique also has better imaging capabilities than TEE, especially for the left atrial appendage and the left ventricular apex (4).