Large Cardiac Varix Associated With Stroke
A 58-year-old man with a history of hypertension presented after a transient episode of left arm and hand numbness and uncoordination that resolved within 1 hour. On admission, he was hypertensive; the remainder of the physical and neurological examinations was normal except for mild left hand dysmetria on finger-to-nose testing. A 12-lead ECG and chest x-ray were normal. A computed tomography (CT) scan of the head was negative for hemorrhage but did demonstrate a nonspecific area of hypodensity in the right frontal lobe. A carotid ultrasound was normal. The patient underwent transesophageal echocardiography (TEE) to investigate the intracardiac source of an embolism. The TEE demonstrated a large (3 cm × 2 cm) mobile right atrial (RA) mass attached to the postero-inferior portion of the atrial septum. The mass appeared encapsulated, with a rim of subcapsular echolucency and an echodense core (Figure 1 and Movie). It contained a small, bright, mobile echodensity. A large patent foramen ovale was also evident by 2-dimensional and color flow imaging. Right-to-left shunting during Valsalva release was demonstrated after agitated saline contrast injection. The remainder of the TEE study was unremarkable. A CT of the chest and abdomen showed no extracardiac extension of the RA mass (Figure 2 and Movie). A coronary angiogram showed no significant coronary artery disease and the patient underwent an uneventful resection of the RA mass and closure of the patent foramen ovale. During the resection, the mass was opened and was found to be a blood-filled cyst containing a calcified kernel (Figure 3 and Movie). Immunohistochemical studies of the cystic tissue were performed; the cells lining the cyst were positive for CD31 and negative for keratin AE1/AE3, which was consistent with the diagnosis of cardiac varix. The calcified kernel was a phlebolith. A cardiac varix is one of the rarest primary cardiac tumors, may be mistaken for a myxoma, and has rarely been reported antemortem in humans.
The online-only Data Supplement, which contains a movie, can be found at http://circ.ahajournals.org/cgi/content/full/114/2/e37/DC1.