Differentiation of Intracardiac Masses: Thrombus, Myxoma, Vegetation, and Tumor in Echocardiography
Contrast Echocardiography in Mass Differentiation
According to the practical guideline of the British Society of Echocardiography (2023), the pattern of ultrasound contrast agent (UCA) accumulation allows differentiation of types of intracardiac masses. Myxomas exhibit patchy perfusion. An avascular mass that does not accumulate contrast and is located over an akinetic area of myocardium is highly likely to be a thrombus.
To identify and characterize intracardiac thrombi and masses, it is recommended to use off-axis images and record longer loops (BSE, 2023).
Assessment of Right Ventricular Masses
In attempts to diagnose regional wall thickening abnormalities, tumors, and thrombi in the right ventricle (RV), the introduction of UCA helps distinguish these pathological formations from normal structures. For positioning the RV in the near field, a modified apical four-chamber view focused on the RV (RV focussed view) or a parasternal view is used (BSE, 2023).
Descriptive Features of Masses in a Standardized Protocol
The ASE guidelines for standardizing adult echocardiography reports (2025) provide descriptive descriptors of masses and structures:
| Descriptor | Characteristic / Example |
|---|---|
| Mural thrombus | Layered appearance |
| Hyperechoic linear mobile mass | Possible artifact / adjacent structures (e.g., left liver lobe in parasternal long-axis view) |
| Lobulated mass | Multiple internal lobules; needs differentiation from encapsulated pericardial effusion and echinococcal cyst (multiple internal locules) |
| Myxomatous degeneration | Thickening, redundancy, and mobility of leaflets |
| Necrotic appearance | Central heterogeneous echolucency |
| Sessile mass with irregular surface | Laminar flow in LVOT confirmed by color Doppler |
Role of Color Doppler
Color Doppler mapping (CFD) is superimposed on 2D or M-mode images and applied in each section, allowing the detection of small eccentric flows. Normal flow is smooth, regular, and corresponds to the phase of the cardiac cycle; pathological flow appears as turbulent (chaotic, disorganized) or eccentric (Blagodir, 2024). Confirmation of laminar flow in the area of the mass can clarify its nature.
Contrast Agents
Ultrasound contrast agents are used to aid in the detection and correct classification of intracardiac masses, including tumors and thrombi (ASE Consensus, 2008). The list includes Levovist, Optison, Definity, SonoVue, CARDIOsphere, and Imagify with various gases and shell compositions.
Frequently asked questions
How does contrast echocardiography help distinguish a thrombus from a tumor?
By the pattern of contrast accumulation: myxomas exhibit patchy perfusion, while an avascular mass without contrast uptake over akinetic myocardium is highly likely to be a thrombus (BSE, 2023).
What sections are recommended for characterizing intracardiac masses?
Off-axis images and recording longer loops. For right ventricular masses, a modified apical four-chamber view focused on the RV or a parasternal view is recommended (BSE, 2023).
What echographic feature is characteristic of a mural thrombus?
According to ASE (2025), a mural thrombus is described as having a layered appearance.
How to differentiate a lobulated tumor from cystic formations?
A lobulated mass is differentiated from encapsulated pericardial effusion and echinococcal cyst, where multiple internal locules indicate a cystic nature (ASE, 2025).
How does color Doppler assist in mass evaluation?
CFD allows confirmation of flow characteristics: in a sessile mass with an irregular surface, laminar flow in LVOT may be confirmed, clarifying the nature of the formation (Blagodir, 2024; ASE, 2025).