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A 83-year-old man with hypertensive cardiomyopathy with left ventricular dysfunction diagnosed 5 years before (without coronary artery disease) in permanent atrial fibrillation since 8 years, was admitted to the ER for heart failure. He was not in anticoagulation therapy because contraindication for the presence of cerebral venous angiomas found several years before. An urgent ultrasound scan was performed that showed bilateral intra-atrial masses. UFH was started. The echocardiography(Fig. 1 panel A)show within the left atrium an isoechoic, not pedunculated mass, 8x5 cm, with lobulated margins, attached to the anterior wall and left atrial appendage, and expanding in the atrial cavity. Within the right atrium a smaller mass with the same characteristics was attached to the anterior wall, 4 x 3 cm (Fig. 1 panel B). TEE confirmed these characteristics and showed also vacuolated aspects inside the masses (Fig. 1 panel C). MDCT was then performed, the atrial masses appeared morphologically very similar to atrial myxomas, but they didn’t enhance iodine contrast agent resembling a typical thrombus behavior (Fig. 1 Panel D). No systemic emboli nor extracardiac tumors were found. CMR could not be performed due to patient claustrophobia. Considering intra-atrial thrombi as a main hypothesis, the treatment with UFH was continued and the masses were monitored by TTE. However, after more than one week the masses volume did not change. A contrast echocardiography with IV Sonovue was performed. A mild contrast enhancement of left atrial mass was seen, thus suggesting the diagnostic hypothesis of cardiac tumor (Fig. 1 Panel E). In this context we decided to perform transvenous biopsy of right atrial mass under intracardiac echocardiography guidance. The biopsy samples from the outer wall of the right atrial mass showed thrombotic features. After a long discussion in heart team, patient underwent to surgical resection of the masses through atrial approach and the surgical inspection was suggestive of neoplastic origin. The histological examination was performed showing thrombotic material with several phases of organization and mild aspects of neo-angiogenesis combined with mild lymphocyte infiltration and necrosis areas (Fig. 1 Panel F). We hypothesized that the histological features of the lesion, with the presence of vessel within the mass could explain the mild late contrast enhancement at Sonovue echocardiography simulating the features of cardiac tumor. In summary, in this case, despite a multimodal imaging approach, the nature of the bilateral intra-atrial masses could not be defined and the histological examination after surgical removal had a key diagnostic role showing organized thrombotic material. A proper differential diagnosis is extremely important in order to decide the appropriate treatment, but sometimes it is extremely challenging. Abstract 1111 Figure 1

1111 Atrial thrombi or cardiac tumors? The challenge of multimodality imaging of intracardiac masses