Comments and illustrations on the complementary use of contrast-enhanced (endoscopic) ultrasound in cardiac tumors

Primary cardiac tumors are rare, accounting for less than 0.1% of all neoplasms, whereas secondary cardiac involvement is considerably more frequent, particularly in advanced oncological disease. Although imaging modalities such as echocardiography, cardiac magnetic resonance imaging, computed tomography, and positron emission tomography are routinely used for the diagnosis and characterization of cardiac masses, the role of contrast-enhanced ultrasound (CEUS) has not yet been systematically evaluated. CEUS enables real-time visualization of vascularity and perfusion and offers important advantages for distinguishing tumors from thrombi, characterizing benign and malignant lesions, and detecting embolic sequelae in distant organs. In this review, we summarize current knowledge on the epidemiology, pathology, and clinical presentation of cardiac tumors and provide an overview of imaging strategies with a particular focus on CEUS. We illustrate the application of CEUS in the assessment of benign tumors such as myxomas and papillary fibroelastomas, rare benign entities, malignant cardiac tumors including sarcomas and lymphomas, and secondary cardiac involvement due to metastatic disease. The diagnostic value of CEUS is highlighted through image and video examples, demonstrating its ability to delineate perfused versus non-perfused tissue and to differentiate tumor vascularity patterns. CEUS represents a promising and underutilized imaging technique in the evaluation of cardiac tumors. It complements established imaging modalities, provides unique pathophysiological insights, and has the potential to improve diagnostic accuracy and clinical decision-making in selected patients.