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Evaluation of Cardiac Masses

Variant: 1   Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US echocardiography transthoracic resting Usually Appropriate O
MRI heart function and morphology without and with IV contrast Usually Appropriate O
CT heart function and morphology with IV contrast Usually Appropriate ☢☢☢☢
US echocardiography transesophageal May Be Appropriate (Disagreement) O
MRI heart function and morphology without IV contrast May Be Appropriate (Disagreement) O
CTA chest with IV contrast May Be Appropriate (Disagreement) ☢☢☢
Radiography chest Usually Not Appropriate ☢
Arteriography coronary with ventriculography Usually Not Appropriate ☢☢☢
MRA chest with IV contrast Usually Not Appropriate O
MRA coronary arteries without and with IV contrast Usually Not Appropriate O
MRI chest with IV contrast Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
CTA coronary arteries with IV contrast Usually Not Appropriate ☢☢☢
DOTATATE PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢
FDG-PET/MRI heart Usually Not Appropriate ☢☢☢
MIBG scan whole body with SPECT or SPECT/CT chest Usually Not Appropriate ☢☢☢
FDG-PET/CT heart Usually Not Appropriate ☢☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
Octreotide scan with SPECT or SPECT/CT chest and abdomen Usually Not Appropriate ☢☢☢☢

Variant: 2   Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
US echocardiography transesophageal Usually Appropriate O
US echocardiography transthoracic resting Usually Appropriate O
MRI heart function and morphology without and with IV contrast Usually Appropriate O
FDG-PET/MRI heart Usually Appropriate ☢☢☢
CT heart function and morphology with IV contrast Usually Appropriate ☢☢☢☢
FDG-PET/CT heart Usually Appropriate ☢☢☢☢
MRI heart function and morphology without IV contrast May Be Appropriate O
DOTATATE PET/CT skull base to mid-thigh May Be Appropriate ☢☢☢
MIBG scan whole body with SPECT or SPECT/CT chest May Be Appropriate ☢☢☢
Octreotide scan with SPECT or SPECT/CT chest and abdomen May Be Appropriate ☢☢☢☢
Radiography chest Usually Not Appropriate ☢
Arteriography coronary with ventriculography Usually Not Appropriate ☢☢☢
MRA chest with IV contrast Usually Not Appropriate O
MRA coronary arteries without and with IV contrast Usually Not Appropriate O
MRI chest with IV contrast Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
CTA coronary arteries with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 3   Adult. Known cardiac mass. Established etiology. Follow-up imaging.
Procedure Appropriateness Category Relative Radiation Level
US echocardiography transthoracic resting Usually Appropriate O
MRI heart function and morphology without and with IV contrast Usually Appropriate O
MRI heart function and morphology without IV contrast Usually Appropriate O
FDG-PET/MRI heart Usually Appropriate ☢☢☢
CT heart function and morphology with IV contrast Usually Appropriate ☢☢☢☢
US echocardiography transesophageal May Be Appropriate O
DOTATATE PET/CT skull base to mid-thigh May Be Appropriate ☢☢☢
FDG-PET/CT heart May Be Appropriate ☢☢☢☢
Radiography chest Usually Not Appropriate ☢
Arteriography coronary with ventriculography Usually Not Appropriate ☢☢☢
MRA chest with IV contrast Usually Not Appropriate O
MRA coronary arteries without and with IV contrast Usually Not Appropriate O
MRI chest with IV contrast Usually Not Appropriate O
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
CTA coronary arteries with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
Octreotide scan with SPECT or SPECT/CT chest and abdomen Usually Not Appropriate ☢☢☢☢

Panel Members
Prabhakar Shantha Rajiah, MDa; Kate Hanneman, MD, MPHb; Bradley D. Allen, MDc; Colin Crowe, MDd; Ahmed H. El-Sherief, MDe; Ihab Hamzeh, MDf; Joe Y. Hsu, MDg; Phillip H. Kuo, MD, PhDh; Veronica Lenge de Rosen, MDi; Juan C. Lopez-Mattei, MDj; Purvi Parwani, MBBS, MPHk; Rahul D. Renapurkar, MD, MBBSl; Suman Tandon, MDm; Michael A. Bolen, MDn.
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
A. Arteriography coronary with ventriculography
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
B. CT chest with IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
C. CT chest without and with IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
D. CT chest without IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
E. CT heart function and morphology with IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
F. CTA chest with IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
G. CTA coronary arteries with IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
H. DOTATATE PET/CT skull base to mid-thigh
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
I. FDG-PET/CT heart
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
J. FDG-PET/CT skull base to mid-thigh
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
K. FDG-PET/MRI heart
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
L. MIBG scan whole body with SPECT or SPECT/CT chest
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
M. MRA chest with IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
N. MRA coronary arteries without and with IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
O. MRI chest with IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
P. MRI chest without and with IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
Q. MRI chest without IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
R. MRI heart function and morphology without and with IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
S. MRI heart function and morphology without IV contrast
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
T. Octreotide scan with SPECT or SPECT/CT chest and abdomen
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
U. Radiography chest
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
V. US echocardiography transesophageal
Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. Initial imaging.
W. US echocardiography transthoracic resting
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
A. Arteriography coronary with ventriculography
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
B. CT chest with IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
C. CT chest without and with IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
D. CT chest without IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
E. CT heart function and morphology with IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
F. CTA chest with IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
G. CTA coronary arteries with IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
H. DOTATATE PET/CT skull base to mid-thigh
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
I. FDG-PET/CT heart
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
J. FDG-PET/CT skull base to mid-thigh
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
K. FDG-PET/MRI heart
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
L. MIBG scan whole body with SPECT or SPECT/CT chest
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
M. MRA chest with IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
N. MRA coronary arteries without and with IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
O. MRI chest with IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
P. MRI chest without and with IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
Q. MRI chest without IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
R. MRI heart function and morphology without and with IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
S. MRI heart function and morphology without IV contrast
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
T. Octreotide scan with SPECT or SPECT/CT chest and abdomen
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
U. Radiography chest
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
V. US echocardiography transesophageal
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
W. US echocardiography transthoracic resting
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
A. Arteriography coronary with ventriculography
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
B. CT chest with IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
C. CT chest without and with IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
D. CT chest without IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
E. CT heart function and morphology with IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
F. CTA chest with IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
G. CTA coronary arteries with IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
H. DOTATATE PET/CT skull base to mid-thigh
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
I. FDG-PET/CT heart
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
J. FDG-PET/CT skull base to mid-thigh
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
K. FDG-PET/MRI heart
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
L. MRA chest with IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
M. MRA coronary arteries without and with IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
N. MRI chest with IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
O. MRI chest without and with IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
P. MRI chest without IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
Q. MRI heart function and morphology without and with IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
R. MRI heart function and morphology without IV contrast
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
S. Octreotide scan with SPECT or SPECT/CT chest and abdomen
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
T. Radiography chest
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
U. US echocardiography transesophageal
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up imaging.
V. US echocardiography transthoracic resting
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause
The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.
Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.