Cardiac tumors physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dheeraj Makkar, M.D.[2]

Overview

The symptoms may be associated with cardiac conditions such as valve dysfunction, pericardial effusion with tamponade, intracardiac blood flow blockage, arrhythmia, and congestive heart failure. A large majority of cardiac tumors do not produce symptoms and are discovered incidentally. The clinical signs of the tumor vary on its size, anatomical site, rate of growth, and potential complications.

Physical Examination

General Examination

• In patients with pulmonary congestion
  • Confusion, agitation, and irritability may be present,
  • Profuse perspiration, cold extremities,
  • Erect posture (sitting upright), and
  • Cyanosis of the lips.

• Pedal Edema

Vitals

• Blood pressure
  • Hypertension mainly. Hypotension in case of cardiogenic shock due to obstruction.
• Respiratory rate
  • Tachypnea, gasping for breath in case of pulmonary congestion
• Pulse
  • Tachycardia in shock
  • Regularly irregular pulse in Atrial Fibrillation
  • Bradycardia in AV Block

Neck

• Prominent A wave with elevation of JVP may be present.
• A waves may be absent if the tumor occurs with atrial fibrillation.
• Prominent accessory muscles of respiration

Heart

Respiratory Findings

• Fine crackles are audible bilaterally at the pulmonary bases and progress apically as the edema develops.
• Signs could also include rhonchi and wheezing.

Heart Sounds

• Prolapsing of atrial tumor into the mitral valve orifice results in delay in closure of mitral valve producing a loud S1.
• There is a delay in P2, intensity of which depends on the absence or presence of pulmonary hypertension.
• Atrial tumor striking against the endocardial wall may produce an early diastolic sound known as the "tumor plop" and the S1 may be split.
• In some cases S3 and S4 may also be present.

Murmur

• In case of obstruction of mitral valve by the atrial tumor, a diastolic atrial rumble is heard.
• If atrial tumor results in damaging of the mitral valves leading to mitral regurgitation then a systolic murmur is heard at the cardiac apex.
• In case of right atrial tumor, a diastolic rumble due to obstruction of the tricuspid valve and a holosystolic murmur due to tricuspid regurgitation may be present.

Gastrointestinal System

• Right-sided heart failure may be accompanied with painful hepatomegaly, which may progress to hepatic fibrosis and hepatic cirrhosis in persistent congestion.

Pertinent Syndromes Associated with Cardiac Tumors: Focused Physical Examination

• Familial myxoma: It presents with a variety of features called syndrome myxoma or Carney syndrome, as follows:

• Myxomas in heart, breast, skin, thyroid gland, or neural tissue
• Spotty skin pigmentation such as lentigines (ie, flat brown discoloration of skin), pigmented nevi, or both on the face, especially on the lips, eyelids, conjunctiva, and oral mucosa
• Endocrine tumors may manifest as disorders such as Cushing syndrome. The most common endocrine gland manifestation is an ACTH-independent Cushing's syndrome due to primary pigmented nodular adrenocortical disease (PPNAD).
• Multiple cerebral fusiform aneurysms may also be seen in patients with Carney syndrome

• NAME syndrome: It refers to:

• Nevi,
• Atrial myxoma,
• Myxoid neurofibroma, and
• Ephelides (i.e., freckles tanned macules found on the skin)

• LAMB syndrome: It refers to:

• Lentigines,
• Atrial myxoma, and
• Blue nevi