Elisabetta Doria, MD; Piergiuseppe ...

Elisabetta Doria, MD; Piergiuseppe Agostoni, MD FCCP; and Cesare Fiorentini, MD

In an asymptomatic 66-year-old woman presenting a systolic undertone in the pulmonic area, echocardiography evidenced a voluminous mass in the right ventricular efflux tract resembling a cardiac tumor. Histologic finding was that of aberrant normal thyroid. Although the affair of ectopic thyroid tissue in the heart is rare, it should be considered in the differential diagnosis whenever a mass is located at the plain of the interventricular septum and encroaches forward the right ventricular outflow tract. In these cases, a thyroid scintiscan may avoid an unnecessary surgical intervention.

sum of two units dimensional echocardiography is the technique of choice for identification of intracardiac masses, since it recognizes the location of nearly 100 percent of thrombi and neoplasms.[1] It has high sensitivity and specificity in determining morphology, spatial relationships and hemodynamic issues of intracardiac masses. The high risk of complications borne by the agency of catheterization in these diseases is an additional reason for restriction of diagnostic deeds to noninvasive methods. However, despite the progres in ultrasound techniques, the tissue histologic findings frequently remain uncertain.[2] We describe the case of an intraventricular thyroid mass, mimicking a cardiac tumor.

CASE REPORT

A 66-year-old woman was admitted to our hospital with the echocardiographic diagnosis of intracardiac mass. The patient was asymptomatic. Cardiac auscultation revealed a high-sounding midsystolic murmur in the pulmonic area. Physical examination was otherwise normal. upon chest roentgenogram, the only abnormality was a moderate increase of the heart transverse diameter. The ECG showed sinus harmonious flow and complete right bundle branch arrest Routine laboratory test results, including thyroid hormone determination, were normal. sum of two units dimensional echocardiography revealed normal left heart chambers and valves; right atrium and right ventricle were moderately enlarged; a voluminous intracavitary mass encroaching forward the right ventricular outflow tract was visualized (Fig 1) The form was approximately 4 cm drawn out and 3 cm wide and increaseed from the interventricular septum to 2 cm behind the pulmonary valve; it appeared almost immobile, with polished edges and was attached to the septum without a visible stalk; its gray scaly appearance was compact and homogeneous. Anatomy of the pulmonary and tricuspid valves was normal. No other abnormal construction was visualized within the myocardium, in the pericardium, or in the caval veins. At Doppler echocardiography, moderate tricuspid regurgitation and vociferous flow in the pulmonic conus were current Peak velocity of tricuspid regurgitant roll on estimated[3] a peak right ventricular systolic press around 60 mm Hg (Fig 1) The absence of peripheral vein thrombosis, the normal appearance of the right heart valves and walls, and the location of the mass in a high velocity issue region negated the interpretation of an intraventricular thrombus and refer toed a neoplasm.[4] Since there was no evidence of a metastatic origin of the mass, we suspected a primitive cardiac tumor and agreed relating to surgical intervention without further diagnostic investigations.

Intraoperative inspection confirmed the echocardiographic information. proper to the wide infiltration of the cardiac tissue extending from the interventricular septum to the pulmonary conus, the surgeon performed solitary a limited resection of the mass, which, at histology, showed the pattern of normal thyroid tissue. The post-operative course was monotonous Postoperative echocardiogram revealed no other than a slight reduction of the mass size; however, peak right ventricular systolic urgency was reduced to 30 mm Hg A thyroid scintiscan, performed after surgery documented normal aspect and function of the thyroid lobes, as well as thyroid tissue at the heart horizontal (Fig 2).

This case point out tos that the echocardiographic features of cardiac neoplasms may be shared from a rare, benign congenital malformation: cardiac thyroid. Cardiac thyroid is an extremely rare occurrence; to our knowledge alone three cases of thyroid adenomas have been diagnosed by way of intraoperative biopsy.[5-7] Our case is the first in vivo report of cardiac thyroid with normal tissue. At post-mortem examination, cardiac location of thyroid tissue has been finded in the pericardium, in the right ventricule, and in the interventricular septum[8] This peculiar location of thyroid tissue within the heart is related to the contact in the embryon between the developing ventral part of the heart and the pharynx.[8]

Since in vivo reports are surpassingly few, it is hard to put in mind of guidelines for the echocardiographic diagnosis of this disorder. Features shared at the three previously reported cases and the not absent one are the location at the right side of the interventricular septum and partial obstruction of the right ventricular efflux tract. We would move therefore, a preoperative cardiac thyroid scintiscan in patients presenting with these echocardiographic features. The most numerous immediate implication concerns a surgical decision which is mandatory for cardiac neoplasms and may be unnecessary for cardiac thyroid.