ALSHARQIA ECHO CLUB Al Qusaibi HotelAl KhobarMay 23rd 2013

Eric McWilliams MB, FRCPI, FRCP, FACCConsultant Cardiologist Dhahran Health CenterDiplomate of the Certification Board of Cardiovascular Computed Tomography 2008 – 2018Honorary Clinical Senior Lecturer, Brighton and Sussex Medical School August 2009 – August 2014

History

75 yr lady dyspnoea on exertion

Type 2 Diabetes Hypertension Hypothyroidism Hyperlipidemia Glaucoma

No murmurs Chest clear

Echo

Echo

Mass 2.7 x 3.3 cms PA pressure 43mmHg above RA

Transesophageal Echocardiography

3D RTE Left Atrial Surgeons View

Phillips IE 33

What Is It ?

Calcified Amorphous Tumour (CAT)

Mitral Valve Thrombus

Calcified Vegetation Pericardial Teratoma Caseous Calcification

of Mitral Annulus Left Atrial Sarcoma Artefact

CXR

Cardiac CT

CTA

CMR

No Enhancement with Gad

CT CMR

What is it ?

What Is It ?

Calcified Amorphous Tumour (CAT)

Mitral Valve Thrombus

Calcified Vegetation Pericardial Teratoma Caseous Calcification

of Mitral Annulus Left Atrial Sarcoma Artefact

Mitral Annular Calcification Caseous Calcification

Degenerative abnormality 10% of >50yr olds commoner in women

Deposition of calcium between the basal infero-lateral ventricular wall and posterior mitral leaflet

Typically posterior mitral annulus

Soft periannular calcification : calcium, fatty acids and cholesterol

Toothpaste like material

Caseous calcification of the mitral annulus

Caseous Calcificationof Mitral Annulus Rare 0.6% of MAC patients

in echo series 2.7% necropsy series Usually incidental

finding Mitral stenosis can

occur Misdiagnosed as

abscess, cardiac tumour etc

MAC and Caseous calcification similar baseline characteristics:

Elderly, hypertension,coronary artery disease, aortic disease etc

Caseous Calcification

CAT

Calcified amorphous tumor (CAT) was coined in 1997 by Reynolds et al,1 who described 11 cases with non neoplastic cardiac masses characterized by a pedicle and diffuse calcification

Evaluation of Intra- and Extra-Cardiac

Structures Cardiac CT CMR

Evaluation of cardiac mass (suspected tumor or thrombus) A (8)

Patients with technically limited images from echocardiogram, MRI, or TEE

Evaluation of pericardial conditions

Evaluation of cardiac mass (suspected tumor or thrombus) A (9)

Use of contrast for perfusion and enhancement

Evaluation of pericardial conditions (pericardial mass, constrictive pericarditis) A (8)

Appropriateness Criteria ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR

Ghada Al Dossary, BS, RDCS Senior Echo TechnologistEric McWilliams MB, FRCPI,FRCP,FACCDhahran Health Center

Another Mitral Mass 63 year old lady

with chronic renal failure

Multiple Access site failures

Infected Gortex graft MRSA bacteremia

What is the appropriate first imaging test ?

TTE

TEE

TTE or TEE ?

Appropriateness CriteriaThe American College of Cardiology Foundation (ACCF)and the American Society of Echocardiography (ASE)

Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus AureusInfections in Adults and Children 2011

Echocardiography is recommended for all adult patients with bacteremia. Transesophageal echocardiography (TEE) is preferred over transthoracic echocardiography (TTE) .

Another Mitral Mass 63 year old lady

with chronic renal failure

Multiple Access site failures

Infected Gortex graft MRSA bacteremia

TEE May 21st,2013

TEE May 21st,2013

What is It ?

Caseous Calcification of Mitral Annulus

Mitral Cusp Prolapse Vegetation Papillary Fibroelastoma of Mitral

Valve Mitral Thrombus

What is it ?

Mitral Mass Prolapse P2

MCP With Vegetations

Mitral Papillary Fibroelastoma

Staph Aureus Bacteremia

13% of hospital acquired Staphylococcus aureus infection develop endocarditis

31% Staph aureus bacteremia : endocarditis

Echocardiography TEE

MRSA Endocarditis

The S. aureus organism carries particular adhesin molecules : can attack structurally Normal valves

The bacteria can either internalise and persist locally, protected from antibiotic therapy and host defences, or lyse the endothelial cells, causing local tissue destruction and distant emboli

S. aureus endocarditis can present either acutely or with a more indolent presentation

Acute pericarditis as presenting symptom of staphylococcal endocarditis: Mitral valve involvement with fistulous tract from LV to LA and subsequent pseudoaneurysm development. Eric McWilliams, Smriti Saraf, Katarzyna Dickinson World Journal of Cardiovascular Diseases, 2013, 3, 31-33 WJCD

Re-entry on Left Atrial Side

MRSA Endocarditis

TTE versus TEE

The sensitivity for detecting vegetation with 2D TTE is 65 to 80 percent and 95 percent with TEE but depends on vegetation size, location, and the echocardiographic window

The yield of TTE is poor in patients with prosthetic valve endocarditis, but the sensitivity for TEE is 90 percent

TEE Mitral Bioprothesis

Vegetation on MVR