From the Guidelines
The diagnostic workup for a right atrial mass from a general cardiology standpoint should begin with a comprehensive transthoracic echocardiogram (TTE) followed by a transesophageal echocardiogram (TEE) for better visualization of the mass characteristics, attachment site, and mobility. This approach is supported by the ACC/AHA guidelines for the clinical application of echocardiography, which highlights the importance of echocardiography in diagnosing various types of intracardiac masses, including tumors, thrombi, and vegetations 1.
Key Components of the Diagnostic Workup
- Transthoracic echocardiogram (TTE) to initially identify and characterize the right atrial mass
- Transesophageal echocardiogram (TEE) for more detailed visualization of the mass and its attachment site
- Cardiac MRI for tissue characterization to differentiate between thrombus, tumor, or vegetation
- CT imaging of the chest, abdomen, and pelvis to evaluate for metastatic disease if malignancy is suspected
- Laboratory tests, including complete blood count, comprehensive metabolic panel, coagulation studies, and tumor markers
Additional Testing Based on Suspected Etiology
- If the mass appears to be a thrombus, a hypercoagulability workup including protein C, protein S, antithrombin III, factor V Leiden, and antiphospholipid antibodies should be ordered
- For suspected infectious etiology, blood cultures should be obtained
- Tissue diagnosis through biopsy may be necessary, which can be performed via cardiac catheterization or surgical excision
Management and Consultation
- Management depends on the diagnosis but often involves surgical excision for tumors, anticoagulation for thrombi, or antibiotics for vegetations
- Early cardiology and cardiothoracic surgery consultation is recommended as soon as a right atrial mass is identified to guide appropriate management, considering the most common right atrial masses include thrombi, primary cardiac tumors (myxoma, lipoma), metastatic tumors, and vegetations 1.
From the Research
Diagnostic Workup for Right Atrial Mass
The diagnostic workup for a right atrial mass typically involves multimodality imaging, including:
- Transthoracic echocardiogram (TTE) to assess the size, location, and mobility of the mass 2
- Transesophageal echocardiogram (TEE) to better define the mass and its attachment site 2, 3
- Cardiac magnetic resonance (CMR) imaging to evaluate the location, extension, and tissue characterization of the mass 4, 3
- Computed tomography (CT) scan to identify the mass and its relationship to surrounding structures 4, 3
- Nuclear magnetic resonance imaging to further characterize the mass 5
Role of Biopsy and Histological Diagnosis
In some cases, a biopsy may be necessary to affirm the histological diagnosis of the right atrial mass 4, 3. The histopathological examination of the surgically removed specimen can reveal the nature of the mass, whether benign or malignant 5.
Importance of Multimodality Imaging
Multimodality imaging is crucial in the diagnostic workup of right atrial masses, as it allows for a comprehensive evaluation of the mass and its potential impact on cardiac function 4, 2, 3. The choice of imaging modality depends on the specific characteristics of the mass and the patient's clinical presentation.
Surgical and Non-Surgical Management
The management of right atrial masses depends on the nature of the mass, its size, and the patient's overall health status. Surgical resection may be necessary for large or symptomatic masses 4, 5, while non-surgical extraction using devices like the AngioVac aspiration device may be an option for patients with high surgical risk 6.