Masses





Normal variants


CASE 11-1


Left atrial appendage


TEE is often requested before electrical cardioversion or catheter ablation for atrial fibrillation to evaluate the left atrial appendage for the presence of thrombus. Adequate visualization of the atrial appendage requires at least two orthogonal views, using a high-frequency (5 MHz or higher) transducer and with the image zoomed to show the appendage anatomy. This case shows normal views of the left atrial appendage in a patient undergoing coronary artery bypass grafting surgery.



Fig 11.1


In this midesophageal biplane view, atrial appendage is visualized in two-chamber plane (left) with mitral valve obliquely cut. Note normal curved triangular shape of atrial appendage. Using biplane mode, line for second image plane is aligned in center of atrial appendage to show orthogonal view (middle panel). In far right image, normal left atrial appendage has been opened. White arrows (as well as black arrows in middle TEE image ) indicate normal pectinate muscles or trabeculations; it is important to recognize normal variation in size and appearance of these so as not to mistake them for atrial thrombi.



Fig 11.2


With probe rotated to patient’s left side, left upper pulmonary vein as well as prominent ridge of tissue between appendage and left upper pulmonary vein (red arrows) are seen. This ridge can be very prominent in some patients and may cause reverberation artifacts that might be mistaken for thrombus in appendage. Small pericardial effusion (PE) around lateral wall of appendage is noted. In right frame, corresponding 3D image is seen; in video, appendage is noted to be fibrillating. Asterisk indicates pectinate muscle.




CASE 11-2


Eustachian valve


In a patient undergoing cardiopulmonary bypass, baseline echocardiographic images were obtained before cannulation of the inferior vena cava via the right atrium.



Fig 11.3


In TEE bicaval view (left) with transducer advanced toward gastroesophageal junction, a view of the IVC is obtained with better visualization of the Eustachian valve (black arrow) originating at the IVC-RA junction and extending into the right atrium; the linear strand (white arrow) extending from the valve is part of the Chiari network. With biplane imaging (right) , the Chiari network (white arrow) is seen to traverse right atrium, joining Eustachian valve on the left to Thebesian valve (valve of coronary sinus) on the right. Red arrow indicates pacing wire in right atrium.



Fig 11.4


3D TEE imaging shows Chiari network and Eustachian valve in greater detail (black arrow). Pacing wire (red arrow) is seen coming into RA from inferior vena cava.



Fig 11.5


In intraoperative photograph from different patient, right atrium has been opened for placement of IVC cannula. Forceps are grasping edge of Eustachian valve and portion of Chiari network (arrow) is also seen. IVC = inferior vena cava.




CASE 11-3


Lipomatous hypertrophy of the interatrial septum



Fig 11.6


This bicaval view shows normal relationships of interatrial septum. In center are septum primum (SP), fossa ovalis (FO), and septum secundam (SS). SVC = superior vena cava.



Fig 11.7


This multiplanar reconstruction shows increase width of septum secundum, most likely from fatty deposition. Fat is not actually infiltrating septum, but occupies space where during embryogenesis superior part of common atrium invaginates, forming septum secundum.

(From Anderson RH, Brown NA, Webb S: Development and structure of atrial septum. Heart 88:104–110, 2002.) In top two orthogonal images, red arrows indicate fatty deposition, whereas in 3D image seen from left atrial perspective (bottom right), red arrow indicates fossa ovalis, which is somewhat circular as seen in bottom left image.



Fig 11.8


In this patient who presented for TAVR, fatty deposition was more pronounced (red arrows), and fossa ovalis is more slit-like in appearance. Bottom right image was obtained by rotating bottom left image counterclockwise along its horizontal axis.



Fig 11.9


This patient had massive deposition of fat that extended cephalad to envelop SVC, and produce venous congestion of head and neck. At surgery, large amounts of fat were excised and atrial septum reconstructed.




CASE 11-4


Spinal cord



Fig 11.10


With TEE probe rotated posteriorly to image descending thoracic aorta, spinal cord may be seen and should not be mistaken for abnormal finding.




CASE 11-5


Lambl’s excrescence


This 71-year-old woman presented for aortic valve replacement because of severe aortic insufficiency.



Fig 11.11


Preoperative TEE in long- and short-axis views revealed small mobile density (arrows) approximately 3 mm in diameter, which appeared to be attached to edge of a valve leaflet.



Fig 11.12


In left panel, double arrow indicates noncoronary cusp of aortic valve. Single arrow indicates mass seen on TEE. Microscopic examination (right panel) of one of aortic leaflets shows fibroelastic thickening of free edge, with sheets of fibroelastic tissue (arrow), consistent with long-standing aortic regurgitation.



Fig 11.13


In this 3D TEE, short axis of aortic valve from aortic perspective (left) and long axis (right), shows calcified valve, with red arrows indicating excrescences. In real time, their mobility is appreciated.




Comments


Small valve strands that microscopically are fibroelastic tissue are normal components of the aortic and mitral valve that increase in frequency with age. These small strands, often called Lambl’s excrescence, appear as small, linear mobile echoes that are most often attached to the upstream side of the valve (ventricular side of the aortic and atrial side of the mitral valve). However, they are also seen attached to the nodules of Arantius at the tip of the valve cusps, on the aortic side of the valve, as in this case. The clinical importance of valve strands is unclear, with some studies suggesting an association with stroke but other data suggesting that these are an incidental finding associated with age but without clinical consequences.


Suggested reading




  • 1.

    Leitman M, Tyomkin V, Peleg E, et al: Clinical significance and prevalence of valvular strands during routine echo examinations, Eur Heart J Cardiovasc Imaging 15(11):1226–1230, 2014.


  • 2.

    Jaffe W, Figueredo VM: An example of Lambl’s excrescences by transesophageal echocardiogram: a commonly misinterpreted lesion, Echocardiography 24(10):1086–1089, 2007.





Thrombi


CASE 11-6


Left atrial appendage thrombus


This 42-year-old woman was diagnosed with rheumatic heart disease as a child and at the age of 16 had an open mitral valvotomy via thoracotomy. She had been relatively well, but recently became more symptomatic, and was found to have severe mitral stenosis She was referred for mitral valve replacement with a concurrent maze procedure to treat atrial fibrillation.



Fig 11.14


In this cardiac MRI, there is severe LA enlargement, and thickened mitral valve with restricted opening during diastole (white arrow). Interatrial septum (red arrow) is bowed to right, indicative of elevated LA pressure.



Fig 11.15


Intraoperative echocardiography from midesophageal two-chamber view, with careful angulation and rotation to optimize image of left atrium, shows echodensity consistent with thrombus (left, arrow) . Spontaneous contrast is also present in appendage. Sensitivity of TEE for detection of left atrial thrombus is highest when high-frequency transducer (typically 7 MHz) and instrument’s magnification (or resolution) mode is utilized. On the right, 3D TEE from the left atrial perspective shows the appendage and thrombus (arrow) .



Fig 11.16


In another patient with similar presentation, flow in atrial appendage is examined by placing pulsed Doppler sample volume about 1 cm from mouth of appendage. In normal sinus rhythm (left), flow velocity after atrial contraction of at least 0.4 cm/sec toward transducer is normal (arrow). In atrial fibrillation, as in this case, lower-velocity, more frequent flow signals are seen (right).



Fig 11.17


Because of presence of atrial appendage thrombus in patient undergoing maze procedure, left atrial appendage was resected. Surgical specimen (from another patient with similar presentation) shows red thrombus and paler normal trabeculation of atrial appendage. Trabeculations must be distinguished from thrombus on TEE imaging.




Comments


Patients with atrial fibrillation are at risk of systemic embolic events due to thrombus formation in the fibrillating left atrium. Most left atrial thrombi occur in the atrial appendage, which is not well visualized on transthoracic imaging. The sensitivity of transthoracic echocardiography for detection of left atrial thrombus is only about 50%. TEE provides high-resolution images of the left atrium and, with an experienced operator, has a sensitivity and specificity of nearly 100% for detection of atrial thrombi.


Imaging of the left atrial appendage should be performed in at least two orthogonal views, typically at 0 and 90 degrees, using a high-frequency transducer and a zoom high-resolution imaging mode. The use of biplane imaging, supplemented by 3D imaging or 2D imaging with minor changes in angulation and rotation from this image plane, are useful approaches to distinguish normal appendage trabeculations, which move with and connect with the atrial wall, from thrombi, which often protrude and have independent motion. Less often, thrombi occur in the body of the atrium, so that careful examination in multiple image planes of the entire atrium, including the atrial septal region, is needed.


Suggested reading




  • 1.

    Prutkin J, Akoum N: The role of echocardiography in patients with atrial fibrillation and flutter. In Otto CM, editor: The practice of clinical echocardiography, ed 5, Philadelphia, 2016, Elsevier.


  • 2.

    Yamamoto M, Seo Y, Kawamatsu N, et al: Complex left atrial appendage morphology and left atrial appendage thrombus formation in patients with atrial fibrillation, Circ Cardiovasc Imaging 7(2):337–343, 2014.



CASE 11-7


Left ventricular thrombus


This 19-year-old male presented to his local ED with a 9-day history of progressive fatigue, and shortness of breath on exertion. Echocardiography at that time revealed a profound impairment of right and left ventricular systolic function. He was transferred to our hospital and taken to the cath laboratory, where after normal coronary angiography an intraaortic balloon pump was placed for cardiogenic shock. He then was taken to the operating room for placement of cannulae for veno-arterial extracorporeal membrane oxygenation (ECMO).



Fig 11.18


Chest x-ray revealed generalized cardiomegaly. Intraaortic balloon pump is in good position; arrow indicates tip.



Fig 11.19


Transgastric short axis demonstrates dilated LV with end diastolic dimension of 75 mm. Arrow indicates spherical, echo-dense, LV mass along anterior wall. Video images show global LV hypokinesis with severely reduced overall systolic function, as well as larger, less echo-dense, mobile mass adjacent to brighter mass. These findings are consistent with LV thrombus. Other possibilities are unlikely given concurrent LV dilation and dysfunction. Normal structures, such as papillary muscle or trabeculations, would have same echodensity and motion as myocardium.



Fig 11.20


Multiplanar reconstruction from 3D volumetric image acquisition is used to further visualize and measure dimensions of mass. In bottom right frame, full 3D volume demonstrates mass in same view as blue plane (shown in 2D image for measurement in lower left image). Green line shows orientation of image plane shown in upper left, and red shows location of image plane shown in upper right panel. Given clinical history, arrows most likely indicate thrombus, which appears to be attached to junction of anterior wall and anterior portion of interventricular septum.



Fig 11.21


At time of ventriculotomy and LV assist device placement, thrombotic material was removed.




Comments


Left ventricular thrombus is most often seen in the setting of myocardial infarction and cardiomyopathy, and is sometimes associated with hypercoaguable diatheses. Although many diagnostic modalities are used, TTE is the most commonly employed, with or without echo contrast.


Knowledge of the presence of a thrombus is especially important in the workup of an embolic event, and in the patient whose heart is to be manipulated by a cardiac surgeon or interventionalist. TEE is not as sensitive as TEE, as the apex of the LV, where many thrombi reside, may not be well visualized. In this case, the size of the mass allowed easy detection. The clinical context suggested that it was thrombotic material; confirmation came at the time of LVAD placement.


Suggested reading




  • 1.

    Carpenter K, Adams D: Apical mural thrombus: Technical pitfalls. Heart 80:S6–S8, 1998.


  • 2.

    Delewi R, Zijlstra F, Jan Piek J: Left ventricular thrombus formation after acute myocardial infarction. Heart 98:1743–1749, 2012.


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Jan 2, 2020 | Posted by in CARDIOLOGY | Comments Off on Masses

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