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Urgent Need for Diagnosis of a Rapidly Growing Right Atrial Mass

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A middle-aged man with no relevant medical history presented to the emergency department with progressive shortness of breath, a productive cough, fatigue, weight loss, and night sweats for several months. A few days prior to presentation, he had developed palpitations, chest discomfort, and lower-extremity swelling. He denied taking any medications or recent international travel. In the emergency department, he had a normal blood pressure with an irregular heart rate at 104 beats per minute. On examination, he had bilateral basilar crackles and traces of lower extremity edema. An electrocardiogram revealed that he was experiencing atrial flutter. A computed tomographic angiogram showed an acute pulmonary embolism, multiple bilateral pulmonary nodules, mediastinal lymphadenopathy, and a right atrial mass. He then underwent a transthoracic echocardiogram with 2-dimensional speckle-tracking strain, which revealed a 4.5 × 3.6 × 3.1-cm pedunculated right atrial mass attached to the interatrial septum near the fossa ovalis (Figure 1A; Video). Left ventricular function was noted to be reduced and cardiac mechanics by 2-dimensional speckle-tracking strain were markedly abnormal, suggesting a more diffuse myocardial process (Figure 1B).

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A middle-aged man with no relevant medical history presented to the emergency department with progressive shortness of breath, a productive cough, fatigue, weight loss, and night sweats for several months. A few days prior to presentation, he had developed palpitations, chest discomfort, and lower-extremity swelling. He denied taking any medications or recent international travel. In the emergency department, he had a normal blood pressure with an irregular heart rate at 104 beats per minute. On examination, he had bilateral basilar crackles and traces of lower extremity edema. An electrocardiogram revealed that he was experiencing atrial flutter. A computed tomographic angiogram showed an acute pulmonary embolism, multiple bilateral pulmonary nodules, mediastinal lymphadenopathy, and a right atrial mass. He then underwent a transthoracic echocardiogram with 2-dimensional speckle-tracking strain, which revealed a 4.5 × 3.6 × 3.1-cm pedunculated right atrial mass attached to the interatrial septum near the fossa ovalis (Figure 1A; Video). Left ventricular function was noted to be reduced and cardiac mechanics by 2-dimensional speckle-tracking strain were markedly abnormal, suggesting a more diffuse myocardial process (Figure 1B).

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Article Information

Corresponding Author: Sneha Thatipelli, MD, Department of Medicine, Northwestern Memorial Hospital, 251 E Huron St, Chicago, IL 60611 (sneha.thatipelli@northwestern.edu).

Published Online: December 30, 2020. doi:10.1001/jamacardio.2020.6107

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s representative for granting permission to publish this information.

References
1.
Bernheim  A , Gore  A , Goyal  N .  Evaluation of incidental cardiac masses on computed tomography imaging: an algorithmic approach.   J Thorac Imaging. 2019;34(1):W1-W9. doi:10.1097/RTI.0000000000000371PubMedGoogle ScholarCrossref
2.
Parwani  P , Co  M., , Ramesh  T.,   Differentiation of cardiac masses by cardiac magnetic resonance imaging.   Curr Cardiovasc Imaging Rep. 2020;13(1). doi:10.1007/s12410-019-9522-4Google Scholar
3.
Palaskas  N , Thompson  K , Gladish  G ,  et al.  Evaluation and management of cardiac tumors.   Curr Treat Options Cardiovasc Med. 2018;20(4):29. doi:10.1007/s11936-018-0625-zPubMedGoogle ScholarCrossref
4.
Lichtenberger  JP  III , Dulberger  AR , Gonzales  PE , Bueno  J , Carter  BW .  MR imaging of cardiac masses.   Top Magn Reson Imaging. 2018;27(2):103-111. doi:10.1097/RMR.0000000000000166PubMedGoogle ScholarCrossref
5.
Lam  KY , Dickens  P , Chan  AC .  Tumors of the heart: a 20-year experience with a review of 12,485 consecutive autopsies.   Arch Pathol Lab Med. 1993;117(10):1027-1031.PubMedGoogle Scholar
6.
Wang  JG , Li  NN .  Primary cardiac synovial sarcoma.   Ann Thorac Surg. 2013;95(6):2202-2209. doi:10.1016/j.athoracsur.2013.01.030PubMedGoogle ScholarCrossref
7.
Varma  T , Adegboyega  P .  Primary cardiac synovial sarcoma.   Arch Pathol Lab Med. 2012;136(4):454-458. doi:10.5858/arpa.2011-0008-RSPubMedGoogle ScholarCrossref
8.
Cheng  Y , Sheng  W , Zhou  X , Wang  J .  Pericardial synovial sarcoma, a potential for misdiagnosis: clinicopathologic and molecular cytogenetic analysis of three cases with literature review.   Am J Clin Pathol. 2012;137(1):142-149. doi:10.1309/AJCP34ZVFLAUTMGLPubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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