Synopsis
Classify an intracardiac mass as thrombus, tumour, vegetation or mimic and act on embolic, obstructive and infective risk before tissue certainty.
- First exclude artefact and normal variants, then classify by chamber, attachment, mobility, haemodynamic effect, vascularity and clinical setting.
- Thrombus favours stasis sites: LAA in AF/mitral stenosis, LV apex after MI or severe dysfunction, and right atrium around lines or with venous thromboembolism.
- Vegetation is an infected endocardial mass—usually mobile on a valve or device—with fever, bacteraemia, valve destruction or embolic/immunological features.
Key red flags
Positional syncope, acute valve obstruction, stroke/limb ischaemia, coronary embolism or a highly mobile left-sided mass requires urgent surgical/embolism assessment.
Investigation priorities
Confirm the mass, location, attachment, mobility, haemodynamic effect and cavity opacification.
Management branches
Mass or filling defect on echo, CT or CMR.
- Confirm it in a second plane/modality and compare prior imaging; map chamber, attachment, mobility, obstruction and embolic risk while excluding artefact/normal variants.
- Ask immediately about AF/MI/LV dysfunction, venous catheters/DVT, fever/cultures/procedures, cancer and constitutional or embolic symptoms.
Key medicines
WarfarinTypical maintenance 3-9 mg orally once daily, individually titrated; when a VKA is selected for non-mechanical intracardiac thrombus, a common specialist target is INR 2.0-3.0.
ApixabanFor licensed NVAF stroke prevention: 5 mg orally twice daily. Use 2.5 mg twice daily when at least two apply—age at least 80 years, weight 60 kg or less, serum creatinine at least 133 micromol/L—or when creatinine clearance is 15-29 mL/min.