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European Journal of Echocardiography 2007 8(6):505-506; doi:10.1016/j.euje.2006.08.005
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Copyright © 2007, The European Society of Cardiology

Intracardiac echocardiography to guide myocardial biopsy of a primary cardiac tumour

Andrew R.J. Mitchell*, Jonathan Timperley, Lucy Hudsmith, Stefan Neubauer and Yaver Bashir

Department of Cardiology, John Radcliffe Hospital, Oxford, United Kingdom

Received 4 May 2006; received in revised form 14 August 2006; accepted after revision 20 August 2006.

* Corresponding author. Department of Cardiac Rhythm Management, John Radcliffe Hospital, Headington, Oxford OX3 9DU, United Kingdom. Tel.: +44 1865 220981; fax: +44 1865 221432. mitcharj{at}doctors.org.uk


   Abstract
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A 61-year-old man presented with recurrent ventricular tachycardia (left bundle branch block morphology, superior axis). Magnetic resonance imaging (Fig. 1) and contrast-enhanced transthoracic echocardiography (Fig. 2) demonstrated an ill-defined mass in the right heart along the free wall of the right atrium, involving the tricuspid valve and extending into the right ventricle. Extensive investigation showed no evidence of extra-cardiac involvement and a tissue diagnosis was recommended. Accordingly, we elected to proceed to myocardial biopsy and, to facilitate accurate tissue localisation, we performed the procedure under guidance with intracardiac echocardiography.

Keywords: Intracardiac echocardiography; Biopsy; Primary cardiac tumour

A 61-year-old man presented with recurrent ventricular tachycardia (left bundle branch block morphology, superior axis). Magnetic resonance imaging (Fig. 1) and contrast-enhanced transthoracic echocardiography (Fig. 2) demonstrated an ill-defined mass in the right heart along the free wall of the right atrium, involving the tricuspid valve and extending into the right ventricle. Extensive investigation showed no evidence of extra-cardiac involvement and a tissue diagnosis was recommended. Accordingly, we elected to proceed to myocardial biopsy and, to facilitate accurate tissue localisation, we performed the procedure under guidance with intracardiac echocardiography. Using local anaesthesia, a 10F AcuNav (Siemens Medical, Erlangen, Germany) echocardiography catheter was inserted via the right femoral vein to the mid-right atrium. Clear views of the size and extent of the mass were obtained, straddling the tricuspid annulus (Fig. 3). Several biopsies were then taken from the right atrial side under close intracardiac echocardiography guidance using access from the right subclavian vein (Fig. 4). Histological examination of the tissue obtained revealed non-Hodgkins lymphoma.


Figure 1
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  		Figure 1 Magnetic resonance imaging of the right heart mass. (RA=right atrium, RV=right ventricle.)

 


Figure 2
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  		Figure 2 Contrast enhanced sub-costal transthoracic echocardiography. (RA=right atrium, RV=right ventricle.)

 


Figure 3
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  		Figure 3 Intracardiac echocardiography of the right heart. (RA=right atrium, RV=right ventricle, TV=tricuspid valve.)

 


Figure 4
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  		Figure 4 Intracardiac echocardiography demonstrating the biopsy forceps. (RA=right atrium, RV=right ventricle.)

 
Intracardiac echocardiography is ideally suited to imaging structures in the right heart. Though its principal uses have been to guide the closure of atrial septal abnormalities and to aid electrophysiological procedures, there are growing indications for its use.1,2 In this case, the intracardiac imaging quality permitted accurate biopsy of a localised intracardiac mass, potentially saving the patient from a more invasive diagnostic procedure.


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Supplementary data associated with this article can be found in the online version, at doi:10.1016/j.euje.2006.08.005.


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  1. Bartel T., Konorza T., Neudorf U., Ebralize T., Eggebrecht H., Gutersohn A., et al. Intracardiac echocardiography: an ideal guiding tool for device closure of interatrial communications. Eur J Echocardiogr (2005) 6(2):92–96.[Abstract/Free Full Text]
  2. Hynes B.J., Mart C., Artman S., Pu M., Naccarelli G.V. Role of intracardiac ultrasound in interventional electrophysiology. Curr Opin Cardiol (2004) 19(1):52–57.[CrossRef][Web of Science][Medline]

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