the histologic confirmation is necessary for the definite diagnosis and is essential in determining the treatment for patients with cardiac tumors . depending on the various clinical situations , tissue diagnosis can be made with less invasive methods including cytologic evaluation of pericardial or pleural fluids , or percutaneous biopsy of metastatic subcutaneous lymph nodes . open heart surgery , mediastinoscopy , and metastatic mass exploration are more invasive methods that require general anesthesia . percutaneous transvenous biopsy of cardiac tumor can be done under the guidance of transesophageal echocardiography ( tee ) . recently , intracardiac echocardiography ( ice ) has been introduced to assist many cardiac procedures and it provides high - quality imaging like tee . although it needs local anesthesia and venous puncture with relatively large catheter , it can give us a good guidance during the biopsy of cardiac tumors . in this report , we present two cases of cardiac masses documented by percutaneous transvenous biopsy under the guidance of an ice . a 51-year - old woman was admitted to our hospital with a 3-day history of progressive dyspnea and generalized edema . the initial electrocardiogram revealed atrial fibrillation with rapid ventricular response , low qrs voltage , and poor r progression . the chest x - ray showed a water - bottle shaped cardiomegaly and bilateral pleural effusion . the transthoracic echocardiogram ( tte ) showed a large amount of pericardial effusion with diastolic right atrial ( ra ) and ventricular collapse associated with inferior vena caval plethora . it revealed infiltrative masses along the superior and posterior aspect of ra wall ( fig . the computed tomographic ( ct ) scan revealed infiltrating mass on ra wall ( fig . 1b ) and multiple tiny nodules scattered in the whole lung fields . because the cytologic examination from the pericardial fluid was inconclusive , we performed percutaneous biopsy of the ra mass in order to establish a pathological diagnosis . after placement of an 8 fr ultra ice catheter ( acunav , siemens medical solution , mountain view , ca , usa ) into the ra , a 6 fr biopsy catheter was inserted into ra and several pieces of ra mass were obtained ( fig . the procedure was well tolerated under local anesthesia , and no complication occurred during the procedure . although the patient was treated with systemic chemotherapy , she died from hepatic rupture associated with multiple liver metastases at 18 months . a 53-year - old man visited our hospital with a 10-day history of progressive dyspnea and weight loss of 4 kg . the ct scan revealed a huge mass infiltrating both atrial wall and posterior mediastinal extension ( fig . 2b ) . because cytologic confirmation of the pleural fluid was negative and percutaneous needle biopsy of the mediastinal mass could be a high - risk procedure , we performed percutaneous ra mass biopsy in order to get prompt specimens . a 6 fr cardiac biopsy catheter and an 8 fr ultra ice catheter were percutaneously inserted into the ra through the right and left femoral vein , respectively . we obtained several pieces of ra mass with the ice monitoring ( fig . 2c and d ) . a 51-year - old woman was admitted to our hospital with a 3-day history of progressive dyspnea and generalized edema . the initial electrocardiogram revealed atrial fibrillation with rapid ventricular response , low qrs voltage , and poor r progression . the chest x - ray showed a water - bottle shaped cardiomegaly and bilateral pleural effusion . the transthoracic echocardiogram ( tte ) showed a large amount of pericardial effusion with diastolic right atrial ( ra ) and ventricular collapse associated with inferior vena caval plethora . it revealed infiltrative masses along the superior and posterior aspect of ra wall ( fig . the computed tomographic ( ct ) scan revealed infiltrating mass on ra wall ( fig . 1b ) and multiple tiny nodules scattered in the whole lung fields . because the cytologic examination from the pericardial fluid was inconclusive , we performed percutaneous biopsy of the ra mass in order to establish a pathological diagnosis . after placement of an 8 fr ultra ice catheter ( acunav , siemens medical solution , mountain view , ca , usa ) into the ra , a 6 fr biopsy catheter was inserted into ra and several pieces of ra mass were obtained ( fig . the procedure was well tolerated under local anesthesia , and no complication occurred during the procedure . although the patient was treated with systemic chemotherapy , she died from hepatic rupture associated with multiple liver metastases at 18 months . a 53-year - old man visited our hospital with a 10-day history of progressive dyspnea and weight loss of 4 kg . the ct scan revealed a huge mass infiltrating both atrial wall and posterior mediastinal extension ( fig . 2b ) . because cytologic confirmation of the pleural fluid was negative and percutaneous needle biopsy of the mediastinal mass could be a high - risk procedure , we performed percutaneous ra mass biopsy in order to get prompt specimens . a 6 fr cardiac biopsy catheter and an 8 fr ultra ice catheter were percutaneously inserted into the ra through the right and left femoral vein , respectively . we obtained several pieces of ra mass with the ice monitoring ( fig . 2c and d ) . the malignant primary cardiac tumors are extremely uncommon , whereas metastatic cardiac tumors occur more frequently.1,2,3 ) in a patient suspected of malignant cardiac tumor without an option for curative surgical treatment , histopathological confirmation is a mandatory option next to treatment strategy , regardless of its primary focus . depending on the various clinical presentations , pathologic diagnosis can be made with less invasive methods such as cytologic evaluation of pericardial or pleural fluids , or percutaneous biopsy of metastatic subcutaneous lymph node . more invasive methods of tumor biopsy through open heart surgery , mediastinoscopy , or metastatic mass exploration may be needed when less invasive approach is not confirmative . percutaneous transvenous biopsy of cardiac tumor is a good alternative using less invasive tool for tissue diagnosis . traditionally , the fluoroscopy guidance is the most commonly used for the blunt endomyocardial biopsy . because the fluoroscopy is inadequate to target the mass lesion , especially in patients with cardiac tumors , many researchers use tte or tee to guide the prompt site for biopsy.4)5 ) however , tte gives less clear cardiac images than tee , especially for the posterior wall mass and the patient with poor echo window,6 ) and tee requires general anesthesia during the procedure . recently , the ice has been introduced to guide several cardiac procedures including device closure for congenital shunts , septal puncture , radiofrequency catheter ablation for arrhythmias , and intracardiac biopsy of tumor.7,8,9,10,11 ) because ice can give us clearer cardiac imaging without using the general anesthesia , it is more practical and patient - friendly . it can also reduce radiation exposure for the echocardiographer during the procedure . in this report , we showed the feasibility of the ice during targeting of the biopsy catheter , without a requirement of patient sedation . the use of ice during the procedures increase diagnostic yield and can reduce the incidence of cardiac complications associated with inadequate targeting of the biopsy catheters . it can be used for the biopsy of the mass from right - side of the heart , especially in patients with high risk for anesthesia.9,10,11 ) these ice - guided techniques allow the physician to safely and effectively perform endocardial biopsy with short total procedure time and less exposure to radiation .
pathologic diagnosis of a cardiac mass is vital in determining the proper treatment modality . 
 open heart surgery or transesophageal echocardiography guided biopsy can be feasible methods to confirm the pathology . 
 however , the former is highly invasive and both methods require general anesthesia . 
 the introduction of intracardiac echocardiography ( ice ) can provide good anatomic information of heart and does not require general anesthesia . in this report , we present two cases of cardiac tumors which were confirmed by percutaneous biopsy under the guidance of an ice . 
 the patients underwent cardiac biopsy without any complications .