Sameh Khalil, MD1,2;Omnia Mohammed, BSc1; Taher Moustafa, BSc1; Ahmed Hamdy, BSc1;Sara Ragab, BSc1; Amina Atef, BSc1; Esraa Maher, BSc1; Shaymaa Ahmed, MSc1; Ahmed Heny, MSc1 and Maha Taher, MD1.Patient
40 years, male
A 40-year-old male patient presented with lower limb oedema, underwent echocardiography which revealed right atrial dilatation and right atrial mass.
For tumour characterisation:
T2WI with fat suppression, T1WI, first pass contrast study after injection of contrast 1, 5 and 10 minutes after contrast injection images were acquired.
For thrombus assessment: delayed post-contrast images were acquired with high inversion time (700 msec).
As regard the mass, there were 2 masses, intra-cavitary, larger one is seen in the right atrium and the smaller one is seen in the right ventricle apex. They showed well-defined outlines, not infiltrative, of low T1WI and T2WI signal in correlation to myocardium with no fatty component.
They showed no enhancement in the first pass perfusion, absent enhancement in early post contrast and delayed enhancement images with no central break down. There was no pericardial infiltration, no valve and no myocardial infiltration.
The large right atrial one measured 6.8 x 5.7 x 4.3 cm in CC x AP x transverse respectively. 15 mm distance above the tricuspid valve annulus. The right ventricular one measured 21 x 7 mm.
Pattern suggestive of benign mass lesions, mostly thrombi.
Endomyocardial fibrosis affects approximately 12 million persons worldwide and is an important cause of restrictive cardiomyopathy in the developing world. It is characterised by apical filling with fibrotic tissue of one or both ventricles (1).
There are well defined known diagnostic criteria of eosinophilic endomyocardial fibrosis by echocardiography which are;
Major criteria (2)
Minor criteria (2)
(3) and (4).
This means that there are CMR diagnostic criteria can help and add to echocardiography in case of equivocal cases, obese patients and poor echocardiographic window.
Differential diagnoses are hypertrophic cardiomyopathy but it is excluded as it doesn’t include obliterated apex or apical notch, it was not a tumor as delayed enhancement images revealed absent enhancement supporting thrombi and it was not a simple primary restrictive cardiomyopathy as it fulfilled the diagnostic criteria of endomyocardial fibrosis.
Endomyocardial fibrosis is a rare type of restrictive cardiomyopathy characterised by progressive interstitial fibrosis involving the Endo-myocardium of ventricles, it has a diagnostic echocardiography checklist of major and minor criteria, yet, there is no consensus about the additive value of tissue characterisation by CMR.
 De Carvalho F, Azevedo C, Comprehensive Assessment of Endomyocardial Fibrosis with Cardiac MRI: Morphology, Function, and Tissue Characterization. Radiographics 2020;40(2):336-353. (PMID: 32004118)
 Mocumbi A, Ferreira M, Sidi D, and Yacoub M. A population study of endomyocardial fibrosis in a rural area of Mozambique. N Engl J Med 2008;359:43-9. (PMID: 18596273)
 Patro S, Kapilamoorthy T, Bodhey N, Gupta A and Sumnyan W. MR imaging in endomyocardial fibrosis. Poster No.: C-187 Congress: ECR 2009.
 Merten C, Beurich H, Zachow D, Arndt F, Moosig F, Richardt G. Cardiac involvement in hypereosinophilic syndromes detected by cardiac magnetic resonance imaging. Journal of Cardiovascular Magnetic Resonance 2015, 17(Suppl 1):Q75.
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