Intracardiac Masses: Epidemiological, Clinical, Therapeutic and Evolutionary Aspects in the Cardiology Department of Yalgado Ouédraogo Teaching Hospital ()
1. Introduction
Intracardiac masses (ICMs) are often discovered while exploring a stroke, valvular heart disease, during a prolonged fever (infective endocarditis), or incidentally [1] [2]. They include intracardiac thrombi (ICT), cardiac tumors and valvular vegetations [3]. Their diagnosis has been improved by the advent of transthoracic DOPPLER (ETT), transesophageal (ETO) ultrasound and cardiac magnetic resonance imaging (MRI) [4] [5]. In the study by Yao et al. in 2014 [2], the prevalence of ICMs in the Asian general population was 1.5‰. However, to the best of our knowledge, no global studies on ICMs in Burkina Faso which takes into account all subgroups (intracardiac thrombus, cardiac tumors, valve vegetation) as well as their evolutionary aspects have been carried out. Hence, we propose to look at the epidemiological, clinical, therapeutic and evolutionary aspects of the IMCs while relying on the data collected within the Cardiology department of Dalgado Ouédraogo Teaching Hospital (CHU-YO).
2. Patients and Method
This was a descriptive study retrospectively collected in the cardiology department from January 1, 2011 to March 31, 2013. Any patients regardless of sex, diagnosed and hospitalized for intracardiac masses was included in the study. Each patient included in the study had been followed-up for at least three months. Patients with ICMs other than tumors, thrombi, and valvular vegetations (pacemaker leads, catheters, anatomical remains, valvular calcifications) were excluded from our study. The variables studied included:
Epidemiologic data: sex, age, marital status, occupation, place of residence and socio-economic level.
Cardiovascular risk factors: age, hypertension; smoking; diabetes; estrogen-progestogen contraception; sedentary lifestyle, obesity etc.
Clinical data studied: dyspnea, headaches, precordialgia, palpitations, temperature, heart rate, blood pressure, and signs of heart failure and motor deficit.
Ultrasound data included the dimensions of cardiac cavities, wall kinetics, shortening fraction, and the presence of tumor, thrombus, or valve vegetation.
Electrical data: heart rhythm disorders; atrioventricular or intraventricular conduction; hypertrophy; repolarization disorders.: ST segment elevation or depression, ischemia/lesion/necrosis.
Laboratory examinations: blood count, azotemia, serum creatinine; blood sugar and lipid check-up.
The therapeutic aspects: the nature of the treatment: medical (anticoagulant, antiplatelet agent, digitalo-diuretic, antiarrhythmic); the treatment duration; the existence or lack of anticoagulant or antiplatelet treatment before hospitalization within the cardiology department.
Evolutionary aspects: the duration of hospitalization, follow-up and survival.
2.1. Data Processing and Analysis
Data processing and analysis were performed through the software EPI info version 3.5.1. Qualitative and quantitative variables were assessed in terms of frequency and average plus or minus, standard deviation. The Comparison of the averages and percentages was performed with the Pearson Chi2 test with a significance threshold p = 0.05.
2.2. Ethic Issues
The ethical considerations were:
3. Outcomes
3.1. Population General Characteristics
Out of the 1066 patients admitted during the study period, 80 had intracardiac masses, corresponding to a hospital frequency of 7.5%. The average age of the patients was 48.4 ± 17.4 years, with extremes of 17 and 84 years. Half the cases were male, corresponding to a sex ratio of as for cardiovascular risk factors, six patients were found to have diabetes in (7.6%) and hypertension was found in 57 (71.3%). A sedentary lifestyle was found in 59 patients (73.8%) and smoking habit in 19 (23.8%). ICM was identified in 18 cases (22.5%) during a thromboembolic complication, and 62 cases (77.5%) had theirs detected through a cardiological check-up for heart disease. Thromboembolic complications included stroke in 55.6% of cases, pulmonary embolism in 27.8%, syncope in 11.1% and acute ischemia of the lower limb in 5.6% of cases. The reasons for cardiology check-up were the following: exertional dyspnea (62 patients) found in 77.5% of cases, precordialgia in 45% (36 patients) and palpitations in 7.5% (six patients).
3.2. Characteristics of Intracardiac Masses
Among these intracardiac masses (ICMs), intracardiac thrombosis (ICT) was observed in 41 cases, representing 50.6% of ICMs and 3.84% of admissions. The other masses were intracardiac tumors and valvular vegetations. Table 1 presents the distribution of the various types of ICMs.
Table 1. Distribution of the various types of intracardiac masses.
Type of mass |
Number |
Percentage (%) |
Intracardiac tumor |
08 |
09.9 |
Thrombosis |
41 |
50.6 |
Valvular vegetation |
32 |
39.5 |
Total |
81 |
100 |
During the echocardiographic examination, we noted that the same ICM could have multiple intracardiac localizations in the same patient. Thus, we noted a bi-cavitary localization of intracardiac thrombi in four patients and the joint presence of vegetations on different valvular apparatuses in six patients. Figure 1 shows the topographical distribution of each type of mass.
Figure 1. Topographical distribution of each type of mass.
3.3. Etiological Factors
In our study, heart failure was found in 65 patients (81.3% of cases), of whom 21.5%. Underlying cardiopathies were dilated cardiomyopathy found in 23 patients (28.8% of cases), ischemic heart disease in 8 patients (10%), and peripartum cardiomyopathy (PPMC) in 3 patients (3.8%). Infective endocarditis was found in 29 patients (36.3%), and decompensated rheumatic valvulopathy in 9 (11.3%).
3.4. Treatment and Evolution
Curative treatment of intracardiac masses consisted of anticoagulation in 65% of cases, antibiotics in 58.8% and instrumental therapy in 1.3%. Oral anticoagulation was used with antivitamin K. Cardiac surgery was not used as a therapeutic option in our study. Twenty patients (25%) died during hospitalization, among which six died (30%) from thromboembolic complications, five (25%) from uncontrolled heart failure, five from cardiogenic shock and four (20%) from septic shock.
The total number of patients who died during our study was estimated at 108, thus bringing the specific mortality associated with intracardiac masses to 18.5%. The average death time was 14.3 ± 13.2 days, with extremes of one and 60 days. The average hospital stay was 17.4 ± 9.8 days, with extremes of 2 and 61 days. The average follow-up period was 12 ± 7.8 months, with extremes of 2 and 26 months. Indeed, one extreme case occurred when one of the patients died in the second month of his/her follow-up. Seven patients died as outpatients (i.e., 8.8% of cases), with an average death time to post-hospital death of 4.6 ± 2.7 months, ranging from 2 to 10 months.
4. Discussion
Several difficulties were encountered in this prospective study. Indeed, the monocentric nature of the study, the frequent absence of anatomopathological examinations to confirm the nature of the mass, the non-compliance with follow-up appointments, and the difficulty of noting deaths occurring at home were the main constraints of the study.
The limited number of studies or scientific works dealing with thrombi, tumors and valve masses at the same time, and addressing epidemiological, clinical, therapeutic and evolutionary aspects, makes it inappropriate to compare some of our results. Indeed, most studies on ICMs are focused on a specific type of mass, specific diagnostic strategies and treatment methods.
Indeed, the prevalence of intracardiac masses has a hospital frequency of 7.5%. Intracardiac thrombi represent the most frequent group of intracardiac masses, as demonstrated in the literature [5] [6]. In our study, the identified intracardiac tumors accounted for 9.9% of all ICMs recorded, or 0.75% of admissions within the cardiology department. Our results are superior to those of Damourou et al. in Togo, who reported a rate of 0.2% for cardiac tumors in their ICM series [7]. This difference can be explained by the sample size (10 cases against 80 cases). We observed 32 cases of valvular vegetations, representing 39.5% of ICMs studied and 3% of admissions within the cardiology department during the period of our study. Elbey et al. in Turkey noted 89% of vegetations in their series, but their study only concerned patients followed-up for infective endocarditis [8]. In 2010, Ralamboson et al. found a sex ratio of 1.5 in their series of cardiac intracavitary thrombi [9]. Once described as rare in women, the high female prevalence could be explained by the increasingly frequent occurrence of cardiovascular pathologies in women, particularly the ones causing intracardiac thrombi (acute myocardial infarction, dilated cardiomyopathy, valvular diseases).
In our study, ICM was diagnosed when a thromboembolic complication occurred in 18 cases (22.5%), including stroke in 55.6%, pulmonary embolism in 27.8%, syncope in 11.1% and acute ischemia of the lower limb in 5.6%. Thomas C et al. reported 5.2% of strokes during a 31-month follow-up period in patients treated for left intraventricular thrombi [10]. Our higher value could be explained by the fact that our study was carried out in a national referral hospital, which often receives immediately complicated cases of ICTs transferred from peripheral health facilities.
In our study, thrombus left intraventricular localization was found in 65.8% of ICT cases. This result is in line with those of Stefano and Davinder, who reported that left intraventricular thrombosis was the most frequent type of ICT, occurring most frequently in heart disease with LV dilatation and in cases of impaired LV systolic function (dilated cardiomyopathy, acute myocardial infarction) [11] [12]. In the literature, left atrial thrombosis is favored by atrial fibrillation and mitral valve disease [3] [13]. They accounted for 29.3% of ICT cases, of which 66.7% of patients had valvulopathy and 41.7% had atrial fibrillation in our series.
The location of the vegetations was predominantly mitral (23.8% of cases) and aortic (17.5% of cases). A predominance of mitral location was reported by Elbey et al. in Turkey (mitral in 43.1% of cases, aortic in 39.1% and tricuspid in 8.9%). The difference in the population size presenting valvular mass during endocarditis could explain the discrepancies in our rates [8].
Therapeutically, except in cases where surgery is indicated, the treatment of intracardiac thrombosis relied on the use of anticoagulants. In the literature, the choice of treatment is sometimes debated, ranging from thrombolysis to thrombectomy. In our study, anticoagulant treatment with low-molecular-weight heparin (LMWH) was initiated in 100% of patients. In 97.6% of cases, LMWH was used in conjunction with AVK. For some authors, the benefit of thrombectomy is comparable to anticoagulation in the case of ICT [14]. Intracardiac thrombosis accounted for 19.5% out of the 18.5% mortality rate for ICM. In-hospital and out-of-hospital mortality in intracardiac tumors was 37.5% and 40% respectively, reflecting their severity. Indeed, most authors agree that surgical removal remains the only therapeutic modality for benign cardiac tumors (myxoma and fibroelastoma) [15]-[17]. However, only symptomatic treatment was used in our patients, which would justify the very high mortality rate.
5. Conclusion
Intracardiac masses visualized on ultrasound are most often due to thrombi, vegetations or myxomas. However, many other benign or malignant tumors are also present. In our study, intracardiac thrombosis was the most frequent mass, accounting for 50.6% of cases. Intracardiac masses are serious because of their high mortality rate (intra-hospital and post-hospital) estimated at 33.7%. Their late diagnosis is a potential source of poor prognosis. They therefore require prolonged monitoring to preserve the patient’s survival. A prospective study on a larger sample deserves to be carried out in order to gather significant data that is likely to help establish a management protocol adapted to our context.