Eva Kusmirek, MD; John D. Grizzard, MD; Kathryn M. Olsen, MD
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KEY FACTS
Terminology
Imaging
TERMINOLOGY
Synonyms
Pseudomasses
Definitions
Entities that appear as masses on initial imaging (usually echo) but often are either normal structures or clinically insignificant variant lesions; usually resolved with cross-sectional imaging (CT or MR)
Normal cardiac variants
Crista terminalis
Normal fibromuscular ridge indenting right atrium (RA)
Demarcates site of fusion of embryologic primitive RA with sinus venosus
Eustachian valve
Variably prominent ridge of tissue at junction of inferior vena cava (IVC) with RA
Directs blood flow toward foramen ovale in fetal life
When prominent, can be mistaken for mass on echo
Other congenital remnants of valve of sinus venosus in RA
Thebesian valve: At junction of coronary sinus with RA
Chiari network: Net-like structure though to be variant of eustachian valve but much more mobile
Taenia sagittalis
Most prominent pectinate muscle in RA
Remnant of septum spurium
Coumadin (warfarin) ridge
Band-like structure in left atrium (LA), between left superior pulmonary vein and left atrial appendage (LAA)
Described as Q-tip sign on transesophageal echocardiography (TEE)
Mistaken for thrombus or mass in echocardiography
Intracardiac benign abnormalities
Lipomatous hypertrophy of interatrial septum (LHIAS)
Hyperplasia of normal fat cells often contiguous with epicardial fat
Fat infiltrates interatrial septum and expands it to diameter > 2 cm but spares fossa ovalis, creating dumbbell shape
May be hot on FDG PET due to composition of brown fat, which is FDG avid
Mitral annular calcification (MAC)
Calcification of fibrous annulus of mitral valve usually occurs as degenerative change
Occurs earlier and is more extensive in renal failure
May appear mass-like in some cases, especially if caseous MAC
Sinus of Valsalva aneurysm
Abnormal enlargement of single sinus, usually right (~ 80%)
Usually congenital in origin, less commonly due to endocarditis
Membranous septal aneurysm associated with ventricular septal defect (VSD)
Redundant septal tissue arising adjacent to membranous VSD that may appear mass-like
May partially occlude VSD
Hypertrophic cardiomyopathy (asymmetric variant)
Extracardiac lesions: Less common causes of confusion on imaging
Hiatal hernia
Complex/loculated pericardial effusion or prominent pericardial fat
Thrombus
Actually mass, not pseudomass, but not neoplasm
IMAGING
General Features
MR Findings
CT Findings
Imaging Recommendations
DIFFERENTIAL DIAGNOSIS
PATHOLOGY
Staging, Grading, & Classification
CLINICAL ISSUES
Presentation
DIAGNOSTIC CHECKLIST
Consider
Image Interpretation Pearls
Selected References
Tumma R et al: Evaluation of cardiac masses by CMR-strengths and pitfalls: a tertiary center experience. Int J Cardiovasc Imaging. 32(6):913-20, 2016
Terpenning S et al: Imaging pitfalls, normal anatomy, and anatomical variants that can simulate disease on cardiac imaging as demonstrated on multidetector computed tomography. Acta Radiol Short Rep. 4(1):2047981614562443, 2015
Anavekar NS et al: Computed tomography of cardiac pseudotumors and neoplasms. Radiol Clin North Am. 48(4):799-816, 2010
Weinsaft JW et al: Detection of left ventricular thrombus by delayed-enhancement cardiovascular magnetic resonance prevalence and markers in patients with systolic dysfunction. J Am Coll Cardiol. 52(2):148-57, 2008
Salanitri JC et al: Cardiac lipoma and lipomatous hypertrophy of the interatrial septum: cardiac magnetic resonance imaging findings. J Comput Assist Tomogr. 28(6):852-6, 2004
Meier RA et al: MRI of right atrial pseudomass: is it really a diagnostic problem? J Comput Assist Tomogr. 18(3):398-401, 1994
Mirowitz SA et al: Fibromuscular elements of the right atrium: pseudomass at MR imaging. Radiology. 182(1):231-3, 1992
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Imaging
TERMINOLOGY
Synonyms
Pseudomasses
Definitions
Entities that appear as masses on initial imaging (usually echo) but often are either normal structures or clinically insignificant variant lesions; usually resolved with cross-sectional imaging (CT or MR)
Normal cardiac variants
Crista terminalis
Normal fibromuscular ridge indenting right atrium (RA)
Demarcates site of fusion of embryologic primitive RA with sinus venosus
Eustachian valve
Variably prominent ridge of tissue at junction of inferior vena cava (IVC) with RA
Directs blood flow toward foramen ovale in fetal life
When prominent, can be mistaken for mass on echo
Other congenital remnants of valve of sinus venosus in RA
Thebesian valve: At junction of coronary sinus with RA
Chiari network: Net-like structure though to be variant of eustachian valve but much more mobile
Taenia sagittalis
Most prominent pectinate muscle in RA
Remnant of septum spurium
Coumadin (warfarin) ridge
Band-like structure in left atrium (LA), between left superior pulmonary vein and left atrial appendage (LAA)
Described as Q-tip sign on transesophageal echocardiography (TEE)
Mistaken for thrombus or mass in echocardiography
Intracardiac benign abnormalities
Lipomatous hypertrophy of interatrial septum (LHIAS)
Hyperplasia of normal fat cells often contiguous with epicardial fat
Fat infiltrates interatrial septum and expands it to diameter > 2 cm but spares fossa ovalis, creating dumbbell shape
May be hot on FDG PET due to composition of brown fat, which is FDG avid
Mitral annular calcification (MAC)
Calcification of fibrous annulus of mitral valve usually occurs as degenerative change
Occurs earlier and is more extensive in renal failure
May appear mass-like in some cases, especially if caseous MAC
Sinus of Valsalva aneurysm
Abnormal enlargement of single sinus, usually right (~ 80%)
Usually congenital in origin, less commonly due to endocarditis
Membranous septal aneurysm associated with ventricular septal defect (VSD)
Redundant septal tissue arising adjacent to membranous VSD that may appear mass-like
May partially occlude VSD
Hypertrophic cardiomyopathy (asymmetric variant)
Extracardiac lesions: Less common causes of confusion on imaging
Hiatal hernia
Complex/loculated pericardial effusion or prominent pericardial fat
Thrombus
Actually mass, not pseudomass, but not neoplasm
IMAGING
General Features
MR Findings
CT Findings
Imaging Recommendations
DIFFERENTIAL DIAGNOSIS
PATHOLOGY
Staging, Grading, & Classification
CLINICAL ISSUES
Presentation
DIAGNOSTIC CHECKLIST
Consider
Image Interpretation Pearls
Selected References
Tumma R et al: Evaluation of cardiac masses by CMR-strengths and pitfalls: a tertiary center experience. Int J Cardiovasc Imaging. 32(6):913-20, 2016
Terpenning S et al: Imaging pitfalls, normal anatomy, and anatomical variants that can simulate disease on cardiac imaging as demonstrated on multidetector computed tomography. Acta Radiol Short Rep. 4(1):2047981614562443, 2015
Anavekar NS et al: Computed tomography of cardiac pseudotumors and neoplasms. Radiol Clin North Am. 48(4):799-816, 2010
Weinsaft JW et al: Detection of left ventricular thrombus by delayed-enhancement cardiovascular magnetic resonance prevalence and markers in patients with systolic dysfunction. J Am Coll Cardiol. 52(2):148-57, 2008
Salanitri JC et al: Cardiac lipoma and lipomatous hypertrophy of the interatrial septum: cardiac magnetic resonance imaging findings. J Comput Assist Tomogr. 28(6):852-6, 2004
Meier RA et al: MRI of right atrial pseudomass: is it really a diagnostic problem? J Comput Assist Tomogr. 18(3):398-401, 1994
Mirowitz SA et al: Fibromuscular elements of the right atrium: pseudomass at MR imaging. Radiology. 182(1):231-3, 1992
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