CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 10, November 2012
e6
AFRICA
sessile manner. The majority of patients are usually in the 30- to
60-
year age group, with a female predominance.
3
The clinical spectrum can be wide, with most affected
individuals presenting with one or more of a triad of symptoms,
including embolic phenomena (as in our patient), intracardiac
flow obstruction (congestive heart failure) and constitutional
symptoms.
4
Myxomas generally have a variable appearance on
MRI. They are hypo-intense relative to the myocardium and
appear heterogenous on T1- and T2-weighted images due to
areas of necrosis, haemorrhage or calcification. Gadolinium-
enhanced MRI generally demonstrates mass perfusion.
5
The
subtle enhancement of the cyst in our patient did not support the
diagnosis of myxoma.
Hydatid disease is a parasitic infestation by
Echonicoccus
granulosus
,
which forms cysts. Cardiac involvement is rare,
seen in approximately 0.5–2% of all cases of hydatid disease
in humans.
6
An extremely rare localisation of the cyst is in a
papillary muscle, which may sometimes require excision of the
valve.
7
The increase in volume and compression of the adjoining
heart structures is responsible for the appearance of symptoms
such as chest pain, palpitation, dizziness, lethargy, dyspnoea
and syncope. The clinical presentation of cardiac hydatidosis
may be non-specific, mimicking valvular lesions, intracardiac
mass, or even heart failure. Although an unusual location for a
hydatid cyst, this diagnosis is possible for the population in our
geographic location.
Papillary fibroelastoma is the third most common primary
tumour of the heart,
2
and is most likely to involve the cardiac
valves. A papillary fibroelastoma is generally considered benign
but can be associated with heart attack, strokeand sudden cardiac
death.
8
Symptoms due to papillary fibroelastomas are generally
the result of mechanical effects or due to embolisation of a part
of the tumour.
Blood-filled cysts are congenital and located on the
endocardium, particularly along the lines of closure of the heart
valves. These thin-walled cysts contain non-organised blood
or sero-sanguinous fluid.
9
Intra-cardiac blood-filled cysts are
typically asymptomatic. These cysts have been described on
the mitral valve, papillary muscles and aortic valve. Cardiac
MRI also could be valuable to differentiate a blood-filled cyst
from other masses. On pre-contrast examinations, blood-filled
cysts are iso-intense compared to myocardium on T1-weighted
images, and hyper-intense on T2-weighted images. The cyst in
our patient did not show signs characteristic of blood.
There is no consensus regarding the optimal management
of these cystic papillary mass lesions. In view of the possible
complications, surgical removal should be given serious
consideraton. There are however no randomised data available
to advocate surgical intervention,
10
even though some studies
show that patients who have undergone surgical treatment have
remained free of cerebral events.
11
Our patient was started on
anticoagulation therapy and followed up with an MRI after six
months, with the assumption that the lesion was not a neoplasm,
based on the imaging findings.
Conclusion
Cystic papillary muscle lesions are rare but important causes of
embolic strokes. MRI plays a significant role in charecterising
cardiac lesions in order to exclude neoplasms and to plan
management, thereby avoiding unnecessary surgery.
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Fig. 2. Coronal MRI demonstrating an abnormal hyper-
intense (a) T2 gradient echo, and enhancing (b) corre-
sponding post-gadolinium lesion in relation to the poste-
rior ventricular papillary muscle.
a
b
Fig. 3. Sagital MRI demonstrating an abnormal hyper-
intense (a) T2 gradient echo, and enhancing (b) corre-
sponding post-gadolinium lesion in relation to the poste-
rior ventricular papillary muscle.
a
b
