Role of Multimodality Imaging and Preoperative Management in Intrapericardial Paragangliomas

Figures

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  Figure 1. Computed Tomography Angiography of the Chest Showing the Paraganglioma The mass (red arrows) is shown in the rotated coronal view (left upper) (Video 1), in the axial view (left bottom), in the rotated sagittal view (right upper), and with 3-dimensional rendering (right bottom). Note that the right coronary artery (open arrow) is encased by the mass. Ao = aorta; LA = left atrium; LV = left ventricle; PA = pulmonary artery; RV = right ventricle.

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  Figure 2. Cardiac Magnetic Resonance Imaging of the Paraganglioma (Top) Axial view shows the mass (red arrow) is centrally positioned in atrioventricular groove and partially encases the right coronary artery (blue arrow). (Middle panels) The lesion is hyperintense on T2-weighted images (left) and shows intense hyperenhancement on perfusion imaging (right) suggesting paraganglioma. (Bottom) The lesion is nonsuppressed on fat saturation T1 (left) and T2 (right) sequences distinguishing this from lipoma. RA = right atrium; other abbreviations as in Figure 1.

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  Figure 3. Transthoracic Echocardiography of the Paraganglioma Parasternal long-axis (left) and parasternal short-axis (right) views showing the PGL (red arrow). The mass clearly abuts the RV and the ascending Ao. Abbreviations as in Figures 1 and 2.

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  Figure 4. Positron Emission Tomography–Computed Tomography Imaging With Gallium-68–DOTATATE of the Paraganglioma The mass is DOTATATE (DOTA-octreotate)-avid, confirming the diagnosis of paraganglioma.

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  Figure 5. Coronary Angiography Displaying the Relationship of the Paraganglioma to the Coronary Arteries (Left) complete occlusion of the right coronary artery (RCA) (asterisk). (Right) RCA (asterisk) was completely collateralized through left-to-right collaterals (red arrows). Moreover, the paraganglioma (open arrow) received feeder vessels from the RCA, left main artery, and left circumflex artery.

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  Figure 6. 3-Dimensional Modeling and Gross Appearance of the Tissue-Confirmed Paraganglioma (Left and middle) Three-dimensional–printed model of the heart with the mass in light blue color overlying the left atrium (red arrows). (Right) Lobulated, well-circumscribed mass with tan color and areas of hemorrhage, highlighting the vascular nature of the surgically excised paraganglioma.

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  Figure 7. Coiling of Feeder Branches From the Coronary Arteries to the Paraganglioma (Left) The left anterior oblique 35° cranial 3° view shows the coiled 2 feeder vessels arising from the left circumflex artery. (Right) The left anterior oblique 35° cranial 17° view shows coiling of the feeder artery arising from a distal branch of the right coronary artery (Video 4).

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  Figure 8. Coronary Angiography Showing Feeder Vessels to the Presumed Paraganglioma as Well as Incidental Coronary Artery Disease Coronary angiogram showing feeder vessel (asterisk) arising from the distal left main coronary artery and tumor blush within the paraganglioma (red arrow) beneath the left main and proximal left anterior descending arteries. A discrete atherosclerotic lesion (open arrow) is seen in the mid left anterior descending artery without evidence of tumor compression.

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  Figure 9. 3-Dimensional Modeling of the Heart With the Paraganglioma Three-dimensional–printed model with the mass in green color (blue arrow). Note the small size of the mass and its proximity to the left main artery and left anterior descending artery (LAD).