Images in cardiovascular medicine. Spontaneous left atrial dissection and hematoma mimicking a cardiac tumor: findings from echocardiography, cardiac computed tomography, magnetic resonance imaging, and pathology.

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Spontaneous Left Atrial Dissection and Hematoma
Mimicking a Cardiac Tumor
Findings From Echocardiography, Cardiac Computed Tomography,
Magnetic Resonance Imaging, and Pathology
Antonella Lombardo, MD; Nicola Luciani, MD; Vittoria Rizzello, MD; Luigi Natale, MD;
Faustino Pennestrí, MD; Riccardo Ricci, MD; Lorenzo Bonomo, MD;
Gian Federico Possati, MD; Filippo Crea, MD
A
with tachycardia and dyspnea. The ECG showed sinus
rhythm (110 bpm). X-rays showed interstitial pulmonary
edema. Transthoracic echocardiography revealed a mild en-
largement of the left atrium (LA), normal left ventricular
function, and a large fixed mass occupying almost entirely the
LA and arriving just near the posterior mitral annulus.
Moderate mitral regurgitation was present. Transesophageal
echocardiography confirmed the presence of an inhomoge-
neous cyst-like mass with a thin hyperechogenic wall coming
from the posterolateral wall of the LA and involving the
interatrial septum roof (Movie). Cardiac computed tomogra-
phy and gadolinium-enhanced magnetic resonance imaging
were also performed (Figure).
On the basis of the findings of the 3 techniques, a
presumptive diagnosis of LA tumor was made and a cardiac
operation was performed with institution of cardiopulmonary
bypass. A vertical extended transseptal incision was made
and an intramural mass was found in the posterior wall of the
LA bulging into and occupying two thirds of the cavity.
Macroscopically, no sign of infiltration was found in and
59-year-old woman with no history of cardiac surgery or
thoracic trauma presented to the emergency department
outside the LA wall, and no pericardial adhesions were
observed. The endocardium was cut and a several clots were
spread out from a non-capsulated cavity delimited by gray,
fibrous, and atrophic tissue. The histopathological examina-
tion showed that the mass consisted of fibrin, erythrocytes,
and scattered leukocytes.
The postoperative course was uneventful and the patient
was discharged on the seventh day. Repeat echocardiography
over the following months showed normal LA without
residual hematoma or dissection and residual mild mitral
insufficiency.
Spontaneoushematomaisaveryrare1,2andchallengingentity
to diagnose even when the best imaging techniques are applied.
Only surgical exploration can clarify the nature of the mass.
References
1. Shaikh N, Rehman NU, Salazar MF, Grodman RS. Spontaneous
intramural atrial hematoma presenting as a left atrial mass. J Am Soc
Echocardiogr. 1999;12:1101–1103.
2. Delgado Jimenez JF, Rufilanchas JJ, Gomez Pajuelo C. Spontaneous left
atrial haematoma. Int J Cardiol. 1991;31:353–356.
From the Cardiology (A.L., V.R., F.P., F.C.), Cardiac Surgery (N.L., G.F.P.), Radiology (L.N., L.B.), and Pathology (R.R.) Institutes, Catholic
University, Rome, Italy.
The online-only Data Supplement, which contains a movie, can be found at http://circ.ahajournals.org/cgi/content/full/114/7/e249/DC1.
Correspondence to Antonella Lombardo, MD, Cardiology Institute, Catholic University, L.go A. Gemelli, 8-00168 Rome, Italy. E-mail
a.lombardo@rm.unicatt.it
(Circulation. 2006;114:e249-e250.)
© 2006 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.orgDOI: 10.1161/CIRCULATIONAHA.106.616268
e249
Images in Cardiovascular Medicine

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A, Transesophageal echocardiography
showing an inhomogeneous mass at the
posterolateral wall of the LA. B, Computed
tomography showing an oval mass not
dissociable from the posterior wall without
significant enhancement after contrast
injection (asterisk). During late phases, a
hyperdense posterior ring is evident (arrow
heads). C, Contrast-enhanced cardiac
magnetic resonance, fast-spin echo
sequence, vertical long axis image show-
ing a hypointense, fixed, oval mass that is
not dissociable from the atrial wall without
contrast enhancement (asterisk), with only
a thin hyperintense posterior band (arrow
heads). D and E, Histology. The mass (5
cm ? 3 cm) consists of a clot (D, bottom
right); the atrial wall at the base of the
mass shows subendocardial fibrosis,
inflammation, and hemorrhage, together
with intramural fibrosis and regressive
changes of myocytes (D, left, and E)
(hematoxylin and eosin staining). D, ?20;
E, ?100.
e250Circulation
August 15, 2006