Table 3.

Differential diagnosis table of intracardiac masses with simultaneous venous thrombosis

Differential Diagnosis	X-Ray	Ultrasound (US)	Echocardiogram	Computed Tomography (CT)	Magnetic Resoance Imaging (MRI)
Paradoxical embolism	Enlarged right sided cardiac chambers	DVT and/or arterial thrombosis	-Presence of PFO, ASD or VSD with right to left or bidirectional shunt. -A thrombus will be visualized through the right to left shunt. -Delayed presence of bubbles on the left side may indicate presence of pulmonary AV connection.	-Presence of right to left shunt, presence of PFO, ASD or VSD and presence of thrombus in the cardiac chambers and through the intracardiac shunt. -CT scan will also show presence of pulmonary embolism.	-Presence of right to left shunt, presence of PFO, ASD or VSD and presence of thrombus in the cardiac chambers and through the intracardiac shunt.
Cardiomyopathy with right and left heart thrombi	-Cardiac chambers may appear to be dilated -Pulmonary congestion	-DVT and/or arterial thrombosis	-Cardiac chamber dilatation -Presence of masses in the right and left side of the heart- -Segmental wall motion abnormality in the heart -Reduction of in the right and/or left ventricular systolic function	-Cardiac chamber dilatation -Presence of masses in the right and left side of the heart- -Segmental wall motion abnormality in the heart -Reduction of the right and/or left ventricular systolic function -The Hounsfield unit of a thrombus is around 40.	-Cardiac chamber dilatation -Presence of masses in the right and left side of the heart- -Segmental wall motion abnormality in the heart -Reduction in the right and/or left ventricular systolic function -A thrombus is T2 hypointense and isointense on T1 weighted images with no hyperenhancement on late gadolinium enhanced images. -A thrombus also lacks fat saturation.
Atrial fibrillation with intracardiac thrombi	-Cardiac, especially atrial chambers may appear to be dilated -Pulmonary congestion	-DVT and/or arterial thrombosis	-Cardiac, especially atrial chamber dilatation -Presence of masses in the right and left side of the heart (atrial thrombi), TEE needed for detection of most common left atrial appendage thrombi	-Cardiac, especially atrial chamber dilatation -Presence of masses in the right or and left atrial side of the heart. -Characteristic of thrombus as above	-Cardiac, especially atrial chamber dilatation -Presence of masses in the right or left atrial side of the heart. -Characteristics of thrombus as above
Cardiac tumors including biatrial myxomas, papillary fibroelastoma and metastatic cardiac tumor	Cardiac chambers usually normal, may appear dilated -Usually negative pulmonary findings (negative congestion)	-DVT	-Usually normal cardiac chambers -Presence of masses in the right and left side of the heart- -Myxoma most commonly arises in the left atrial from side of the interatrial septum but they rarely can be present in both the atria as well as in the ventricles. -Papillary fibroelastoma most commonly occur on the cardiac valves with predilection for left sided cardiac valves. They are usually located away from the free edges of the valves. -Are rarely associated with valve stenosis or regurgitation.	-Usually normal cardiac chambers -Presence of masses in the right and left side of the heart- -Cardiac Myxoma appears more heterogeneous on CT scan.	-Usually normal cardiac chambers -Presence of masses in the right and left side of the heart -Cardiac Myxoma is hypo or isointense on T1 and hyper intense on T2 weighted images, it is bright on perfusion images and shows a heterogeneous pattern of hyper enhancement on late gadolinium enhanced images. -Papillary fibroelastoma appears as a hypo intense mass on cine gradient echo or SSFP images and have a thin stalk usually. -Are rarely associated with valve stenosis or regurgitation.
MI with LV thrombus and simultaneous DVT	Cardiac chambers may appear dilated -Pulmonary congestion	-DVT and/or arterial thrombosis	-Cardiac chamber dilatation and/or LV aneurysm -Presence of mass in the left ventricle (usually apex) -LV segmental wall motion abnormality in the myocardium -Reduction in the right and/or left ventricular systolic function	-Cardiac chamber dilatation and/or LV aneurysm -Presence of mass in the left ventricle (usually apex) -LV segmental wall motion abnormality in the myocardium -Reduction in the right and/or left ventricular systolic function -Thrombus characteristics as above	-Cardiac chamber dilatation and/or LV aneurysm -Presence of mass in the left ventricle (usually apex) -LV segmental wall motion abnormality in the myocardium -Reduction in the right and/or left ventricular systolic function -Thrombus characteristics as above
Right heart thrombus associated with central lines, PICC lines, Swan Ganz catheters and pacemakers/defibrillators in patient who has atrial septal defect or patent foramen ovale	Cardiac chambers may appear dilated. Leads/catheters visualized on x ray	-DVT and/or arterial thrombosis	-Right heart thrombus will be seen on TTE -Presence of pacemaker/catheter/ leads. Dilated right-sided cardiac chambers. -Presence of atrial septal defect	-Cardiac chamber dilatation. -Presence of thrombus in right atrium, inferior or superior vena cava -Presence of ASD or PFO. -Presence of pacemaker/catheter/ leads.	-MRI can be performed in the presence of Swan Ganz catheter or other central lines but is contraindicated in the presence of pacemakers/defibrillators. -Cardiac chamber dilatation. -Presence of thrombus in right atrium, inferior or superior vena cava -Presence of ASD or PFO -Presence of pacemaker/catheter/ leads.
Left sided non-infective and infective endocarditis	-Cardiac chambers may be dilated if associated significant valve regurgitation. -Pulmonary congestion	-DVT and/or arterial thrombosis	-Cardiac chambers may appear dilated if associated significant valve regurgitation. -Presence of masses in the right and left side of the heart valves- -Vegetations most commonly arise from the side of the valve from where the blood enters the valve i.e. on the atrial side in case of mitral and tricuspid valves and on the ventricular side in the aortic and pulmonic valves. -Frequently associated with valve stenosis or regurgitation.	-Cardiac chamber dilatation -Presence of masses in the right and left side of the heart- -Vegetations are usually associated with destruction of valve leaflets. -Frequently associated with valve stenosis or regurgitation. Could be associated with valve stenosis or regurgitation.	-Cardiac chamber dilatation -Presence of masses in the right and left side of the heart- -Vegetations are usually associated with destruction of valve leaflets. -Frequently associated with valve regurgitation. Could be associated with valve stenosis or regurgitation.

Abbreviations: MI: Myocardial infarction; DVT: Deep venous thrombosis; TTE: Transthoracic echocardiogram; TEE: Trans-esophageal echocardiogram; SSFP: Steady State Free precession images; US: Ultrasound: CT: Computed tomography; MRI: Magnetic resonance Imaging: PFO: Patent foramen ovale; ASD: Atrial septal defect; VSD: Ventricular septal defect.