Enigma of Huge mass filling the apical wall of the left ventricle. Is it thrombus, tumor or endomyocardial fibrosis?

Abstract

Background: Cardiac masses have a wide range of etiologies with the most common being thrombi and less commonly tumors. Certain areas of the heart have specific tumor predilections. We present an interesting case in which the diagnosis of the ventricular mass was difficult given the initial symptomatology and the patient's phobia.

Case summary: A 45-year-old male patient with medical history of smoking, was admitted to the emergency room complaining of severe breathlessness, However, the patient declined any chest discomfort or pain.

On physical examination he was dyspneic, with vital signs revealed heart rate of 110 beats/min, blood pressure of 125/90 mmHg. Cardiovascular examination showed regular heart rhythm and normal heart sounds.

Electrocardiogram revealed sinus tachycardia, chest X-ray was suggestive of cardiomegaly.

Transthoracic Echocardiography demonstrated a dilated left ventricle with severely reduced ejection fraction and diffuses kinetic disturbances. The presence of a huge mass filling the apical wall of the left ventricle, hyperechogenic in appearance and very adherent to the ventricle.

In front of this doubtful appearance at the echocardiography the patient was programmed for a cardiac magnetic resonance imaging which could not be carried out because of the claustrophobic state of the patient.

In the meantime, the patient had a cardiac arrest due to refractory ventricular fibrillation successfully resuscitated. In front of this complication, he benefited from an automatic implantable defibrillator as a secondary prevention.

Subsequently, a coronary angiography was performed in the context of the patient's smoking habits and kinetic disorders, to our surprise showed a complete occlusion of the left anterior descending artery knowing that the patient is not diabetic and he never complained of any painful symptomatology, primary coronary intervention was successfully performed to the left anterior descending artery.

The patient was started on therapeutic anticoagulation and heart failure therapy. Follow-up imaging after 6months showed a significant improvement of the left ventricular systolic function and thrombus regression to apical segment without embolic events.

Conclusion: The diagnosis of a ventricular mass remains difficult, the orientation can be done initially by the ground of the patient while being helped by the transtoracic echography and the multimodality imagery at the end to specify the nature of the intra-cardiac mass for an adequate and fast management.

Keywords: Thrombus, ventricular mass, coronary angiography, heart failure, oral anticoagulation.

DOI: 10.7176/JHMN/98-05

Publication date:March 31^st 2022