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What does my MRI scan report indicate?

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Posted on Wed, 15 Feb 2017
Question: My echicardiogram and TEE showed a mass on the tricuspid valve. Cardiac MRI says "no evidence of mass, differential diagnosis fibroelastoma". Isn't a fibroelastoma a benign mass? And are these usually removed?
doctor
Answered by Dr. Ilir Sharka (44 minutes later)
Brief Answer:
I would explain as follows:

Detailed Answer:
Hello!

Welcome on HCM!

I understand your concern and would like to explain that when you are in front of a mass attached to the cardiac valves, it is true that fibroelastoma should be included in the differential diagnosis as it is the third most frequent cardiac primary tumor.

Fibroelastoma is considered a benign tumor, BUT this is true regarding its histological classification, because in clinical settings its behavior may be aggressive and life-threatening.

This latter risk arises from its potential to cause embolization (fragmentation of the tumor mass and its migration with the blood flow up to occluding several important areas in different organs, supplied by the underlying arteries).

Also cardiac masses may lead to valve dysfunction such as regurgitation or stenosis and overall impaired cardiac performance. Also arrhythmia has been noticed in the setting of similar cardiac tumors.

Now, returning to your concrete clinical situation, it is important that other similar causes of cardiac masses be sought systematically such as vegetations, thrombotic masses and even cardiac myxoma.

If a cardiac mass is causing obvious clinical symptomatology (shortness of breath, palpitations {arrhythmia}, loss of conscience or near fainting, chest pain or peripheral edema, etc.), especially if its dimensions are not too small, then surgical excision through a mini-invasive procedure should be consider.

In that way, it would be definitely possible to exactly diagnose the real nature of the cardiac mass through histological microscopic examination.

Hope to have been helpful!

Feel free to ask me again whenever you need!

Kind regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (42 minutes later)
I have uploaded my echocardiogram reports and MRI report. I do have some tricuspid valve regurgitation and thickening of the anterior leaflet of the tricuspid valve, regardless of whether or not there is a tumor. My cardiologist believes that the echo and the TEE images were "skewed" and that there is no mass. He further indicated that the differential diagnosis of a fibroelastoma on the MRI is a "red herring" that would not be addressed. I am very confused because when it was believed that there was a mass and I described my symptoms, my doctor was eager to get me to a surgeon for a consultation. But after reading the MRI report, he now says that my symptoms could not be coming from this valve regurgitation or the so-called mass. I am definitely having fatigue, shortness of breath, light-headedness, headaches, legs swelling and palpitations, all of which have continued to get worse over the past 5 weeks. I had an echocardiogram stress test last week, and my oxygenation stayed good, only dropping to 90, 94 and 95 briefly for a few seconds and then coming right back up, during and after the test. The tricuspid valve regurgitation was noted again, my doctor saying it was about 3m/s, but he said that would not be causing me my symptoms. Do you think that this tricuspid valve thickening or fibroelastoma could be causing all of my symptoms, and should I get a second opinion or see a surgeon for consultation?
doctor
Answered by Dr. Ilir Sharka (2 hours later)
Brief Answer:
My opinion:

Detailed Answer:
Dear XXXXXXX

After carefully reviewing your uploaded cardiac Echo and MRI reports, let me explain as follows starting by your last question:

1- As far as your thickened tricuspid valve and the presumed fibroelastoma do not cause any clinically relevant tricuspid valve stenosis or regurgitation, it doesn't seem that these image findings have a direct implication in your actual complaints.

But from the other hand as we don't know exactly what do these image tests findings really mean (fibroelastoma, vegetation, thrombus, other causes or just incidentaloma [echocardiographic findings without any clinical significance]), it is not sure whether any underlying pathological process is evolving.

Coming to this point, it doesn't seem that a surgeon consultation could get to a more precise conclusion, as far as all the medical opinion is based on imaging cardiac tests.

The most appropriate strategy to arrive to an exact conclusion would be to follow these cardiac echo findings with repeated imaging tests (like trans-thoracic echo) and if possible with 3D echo modality.

Also, contrast enhanced cardiac CT could be helpful for detecting a possible fibroelastoma presence or any alternative intra-cardiac masses.

2- Regarding your recent complaints, I would recommend discussing with your attending physician on the possibility of conducting some additional pulmonary tests such as:

- pulmonary angio CT scan (just to be sure that no potential fragmentations of the presumed intra-cardiac mass have embolized within the pulmonary blood vessels).
- pulmonary function tests
- arterial blood gas analysis.

Hope to have been helpful!

I remain at your disposal if you have any other uncertainties!

Best wishes,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (2 hours later)
Thank you for the detailed response. I did have a CTA, and it was normal, without a demonstrated pulmonary embolism or arterial dissection. Is this test 100% accurate for finding any fragments from a mass that may embolize? Is there any other test that you might recommend to confirm, and if there are fragments, could that possibly explain my symptoms? Or any chance that it coukd be vegetation froman infection, without a fever?
doctor
Answered by Dr. Ilir Sharka (11 hours later)
Brief Answer:
I would explain:

Detailed Answer:
Hello again,

A pulmonary CTA scan is quite accurate at confirming/excluding the presence of pulmonary embolism along the pulmonary arteries network up to segmental pulmonary artery branches.

If a more sophisticated device is used such as multi-row CTA, then the accuracy of detecting subsegmental pulmonary artery embolism increases further.

Alternative medical test at detecting pulmonary embolism with a high accuracy is the pulmonary ventilation/perfusion scan.

If multiple small pulmonary emboli are detected, this may explain at some degree your recent complaints, but in such case it would be more important to reveal the reasons why the pulmonary embolism occurred (as a secondary disease would be responsible).

Vegetation could not be easily excluded; and the possibility of non-infectious (without fever) vegetations such as in the case of non-bacterial thrombotic endocarditis exists.

If this is confirmed, several pathological disorders should be sought, such as certain systemic disorders, hypercoagulable states (including oral contraceptive pills), certain tumors, etc.

Hope to have clarified your uncertainties!

Kind regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (27 hours later)
Thank you so much again. One last question...I suffer from chronic genital herpes and shingles. Could the herpes virus be responsible for my recent symptoms?
doctor
Answered by Dr. Ilir Sharka (1 hour later)
Brief Answer:
I would explain as follows:

Detailed Answer:
Dear XXXXXXX

Regarding your concern, I would explain that it is really less likely that your symptoms are related to herpes infection or shingles.

The most common features of these infections are skin eruptions and neuropatic pain (which is felt like electric shock) in the the region inervated by a certain nerve.

So, your symptoms are not characteristic of any of these infections.

Hope you will find this answer helpful!

Wishing all the best,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (15 days later)
I have uploaded my ecg from my echo stress test. Can you tell me if you see any indication of afib?

We are thinking that it might be possible that I am going in and out of afib, so they are putting me on a 30-day monitor. I have a very short pr interval and have had that for several years, but recently, my symptoms have changed. I had a period of about 4 weeks where I was constantly having heart palpitations, fluttering, chest pain and fatigue, and now I am having fewer palpitations and better strength.

I want to make sure that this ecg was analyzed closely enough to indicate any evidence of afib during the stress test. I was having sypmtoms frequently during the week of the test.

Thank you.

doctor
Answered by Dr. Ilir Sharka (5 hours later)
Brief Answer:
Opinion as follows:

Detailed Answer:
Dear XXXXXXX

I carefully reviewed all the fourteen pages of your uploaded file and would like to explain that there are no signs of atrial fibrillation in any of them.

All the registered tracings conclude normal sinus rhythm, without any episodes of irregular rhythm.

Anyway, I agree with your doctor on the decision to perform a longer heart rhythm monitoring, which could be more appropriate in detecting rare potential episodes of arrhythmia.

Another point to carefully consider is the short PR interval, which could be a prerequisite for triggering re-entry tachycardia through potential accessory bypass pathways (from the atria down to the ventricles); Long Ganong Levine syndrome should be ruled out in this regard.

Hope to have been helpful to you!

Fell free to ask me again, in case of any further uncertainties.

Best wishes,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka (3 days later)
Thank you again for your help. My doctor has indicated that he believes I have Long Ganong Levine Syndrome, but he said they wouldn't treat that unless it was giving me episodes that "put me on the ground". I am trying to put clues together myself, as my doctors continue to run tests, but I am frequently getting a fullness in my throat with activity that leads to a headache, along with some random episodes of palpitations. I also have a fullness in my abdomen that makes me feel as though I need to stretch up to get comfortable. I have had my thyroid tested, and it is normal, and I had an abdominal ultrasound that was normal as well. Is it possible that I might have a hiatus hernia that could be causing my symptoms by irritating the vagus nerve? And would that have shown up on my chest x-ray or CT scan? I am considering going to a gastroenterologist while I am doing this 30-day monitor, but I don't know if that is worth doing.
doctor
Answered by Dr. Ilir Sharka (2 hours later)
Brief Answer:
I would explain as follows:

Detailed Answer:
Dear XXXXXXX

As you are on Heart rhythm monitoring and are supposed to have Levine syndrome, it would be better to confirm/rule out whether those palpitations are arrhythmic episodes before undertaking any further diagnostic work up.

And regarding a potential hiatal hernia, I would explain that such a finding could be easily detected on your chest CT scan or MRI. So, I don't believe that hernia would be the cause of those complaints in your case.

But, if you have other suggestive signs and symptoms (pyrosis [heartburn],or associated pain, etc.) then you could try a gastric anti-secretor drug and consult your gastroenterologist.

In addition, some of your unpleasant feelings could be triggered by anxiety.

That's why I would advise you to consider some daily activities that could help you relaxing and mitigate potential accumulated stress.

Outside walking, aerobics, yoga, cycling could be offer a great relief from daily stress.

When any heart monitoring results is available, please upload them here for a second professional opinion.

Greetings!

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Ilir Sharka

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What does my MRI scan report indicate?

Brief Answer: I would explain as follows: Detailed Answer: Hello! Welcome on HCM! I understand your concern and would like to explain that when you are in front of a mass attached to the cardiac valves, it is true that fibroelastoma should be included in the differential diagnosis as it is the third most frequent cardiac primary tumor. Fibroelastoma is considered a benign tumor, BUT this is true regarding its histological classification, because in clinical settings its behavior may be aggressive and life-threatening. This latter risk arises from its potential to cause embolization (fragmentation of the tumor mass and its migration with the blood flow up to occluding several important areas in different organs, supplied by the underlying arteries). Also cardiac masses may lead to valve dysfunction such as regurgitation or stenosis and overall impaired cardiac performance. Also arrhythmia has been noticed in the setting of similar cardiac tumors. Now, returning to your concrete clinical situation, it is important that other similar causes of cardiac masses be sought systematically such as vegetations, thrombotic masses and even cardiac myxoma. If a cardiac mass is causing obvious clinical symptomatology (shortness of breath, palpitations {arrhythmia}, loss of conscience or near fainting, chest pain or peripheral edema, etc.), especially if its dimensions are not too small, then surgical excision through a mini-invasive procedure should be consider. In that way, it would be definitely possible to exactly diagnose the real nature of the cardiac mass through histological microscopic examination. Hope to have been helpful! Feel free to ask me again whenever you need! Kind regards, Dr. Iliri