case presentation: 47 year-old male with sudden weakness,

Case Presentation

Federico Viganego, M.D.

1/19/07

Case 1-H.H.

• 61 y.o. M recently diagnosed with a right renal mass

• Presented to the hospital with progressive dyspnea and worsening renal function

• A 2D echo is ordered to evaluate the cause of dyspnea..

Echocardiogram

Case 1-H.H. 2D ECHO

• Image 38

• Image 42

• Images 60-66

• Image 69-79

Case 1-H.H.

• A mass is visualized in the R atrium. The mass is mobile, originates from the IVC, and is compatible with thrombus.

• The RA mass measures 14 x 7 mm

• A MRI of the abdomen is performed..

MRI

MRI

MRI

MRI

MRI

MRI

MRI-CORONAL VIEW

MRI-SAGITTAL VIEW

MRI-SAGITTAL VIEW

MRI-SAGITTAL VIEW

Case 1-H.H.

• A large mass is identified in the right kidney

• A large thrombus is seen in the R renal vein and within the infra-renal IVC extending to the level of iliac bifurcation

• Thrombus is also seen within the IVC extending superiorly to the atrio-caval junction

Case 1-H.H.

• Pt undergoes embolization of the R renal artery on 12/22 and a repeat embolization of residual renal artery on 1/3

• On 1/11 pt underwent R radical nephrectomy, supradaphragmatic IVC thrombectomy, and splenectomy

Cardiac Masses

• Abnormal structure within or immediately adjacent to the heart

Three types of cardiac masses:

• Tumor

• Thrombus

• Vegetation

Cardiac Mass-Echocardiography

• Pro: • Can provide both anatomic and physiologic

information about the mass • Noninvasive, relatively inexpensive• Serial studies are feasible• Cons: • Suboptimal image quality in some patients• Relatively narrow field of view (vs.CT/MRI)• Mass versus ultrasound artifact• Mass versus normal structures

Diagnosis of Intracardiac Mass

• Excellent image quality

• Identification in more than one acoustic window

• Knowledge of normal structures, normal variants and post-op changes

• Integration of other echo findings (i.e., rheumatic MS and LA thrombus)

• Clinical data

Cardiac mass vs. normal structuresRight Atrium

• Crista terminalis

• Chiari network (Eustachian valve remnants)

• Lipomatous hypertrophy of the interatrial septum

• Trabeculation of the RAA

• Atrial suture line (transplant)

• Pacer wire, Swan-Ganz catheter, CVC, etc

Eustachian valve remnants

• Persistent portions of embryologic valves of sinus venosus

• Junction of IVC/SVC with RA

• Typically mobile

• May be extensive → Chiari network

• Do not extend to cross the tricuspid valve

Chiari Network

Pacer Wire

Right-sided thrombi

• Rarely form in situ

• Most commonly embolized from venous source

• May be ‘entrapped’ in TV or RV structures

• Indwelling catheters or pacer wires

• Better characterized with TEE

• If mobile, differential include Eustachian valve remnants

Risk of embolization

Higher: • Irregular shape• Protruding in the

cavity• Mobile• Seen in multiple

projections

Lower:• Flat• Immobile• Seen in single

projections

Distingushing intracardiac massesCharacteristic Thrombus Tumor Vegetation

Location LA (esp. if enlarged or MV disease)

LA (myxoma)

Myocardium

Pericardium

Valves

Usually valvular

Occasionally on ventricular wall or Chiari network

LV (↓EF or segmental wma)

Appearance Usually discrete and somewhat spherical or laminated against LV apex or LA wall

Various: may be circumscribed or irregular

Irregular shape, attached to prox side (upstream) of the valve with motion independent from the valve

Associated findings Underlying etiology usually evident

Intracardiac obstruction depending on site of tumor

Valvular regurgitation usually present

LV systolic dysfn or segmental wma

Fever, systemic signs of endocarditis, positive blood cultures

MV disease with LAE

Cardiac mass vs. normal structuresLeft Atrium

• Dilated coronary sinus (persistent L superior vena cava)

• Raphe between L superior pulmonary vein and LAA

• Atrial suture line (transplant)

• Beam-width artifact from calcified aortic valve, AV prosthesis, etc.

• Interatrial septal aneurysm

Cardiac mass vs. normal structuresLeft Ventricle

• Papillary muscles

• Left ventricular web (aberrant chordae)

• Prominent apical trabeculations

• Prominent mitral annular calcification

Cardiac mass vs. normal structures

Right Ventricle:• Moderator band• Papillary muscles• Swan-Ganz catheter

or pacer wire

Aortic Valve:• Nodules of Arantius• Lambl’s excrescenses• Base of valve leaflet

seen en face in diastole

Case 2-D.J.

• 74 y.o. F presents with progressively worsening dyspnea and bilateral pleural effusions. Recently hospitalised for repeated syncopal episodes.

• PMH: HTN, CAD, TIAs, Rheumatoid arthritis

• MEDS: Methotrexate, Toprol, HCTZ, Lisinopril

• SOCIAL: 40 pack-year tobacco hx

Case 2-D.J. Echo

• Image 10

• Image 15

• Images 39-40 and 44

• Images 45-51

• Image 58

Case 2-D.J. 2D Echo

• Normal LV with normal to hyperdynamic systolic function

• Mild LVH• Severe MAC. Moderate MS (MV area by

pressure half-time=1.5 cm2, mean gradient=11 mmHg)

• Calcified aortic valve with moderate AS by continuity equation (AVA 1.4 cm2)

• Mild to moderate TR. Severe PHTN

Case 2-D.J. TEE

Case 2-D.J. TEE

Case 2-D.J. cath

Case 2-D.J. cath

• RH cath: RA pressures 8 mmHg, RV 31/6, PAP 57/25,

• Simultaneous pressures: PCWP 24 mmHg, LVEDP=8-11 mmHg, trans-mitral valve gradient 13-16 mmHg

• CO=2.67 L/min (thermodilution)• CI= 1.75 L/min/m2• Coronary angio: LAD 60-70% mid, LCX minor

lum irreg, RCA 50-60% prox-mid• LV-gram= normal LV filling and LV fn, MR2+• Normal ascending aortogram

CASE 2-D.J.-2D ECHO recent

Mitral StenosisRheumatic mitral stenosis.

There are severe valvular changes, including marked fibrosis and calcification of the mitral valve leaflets and severe chordal thickening and fusion into pillars of fibrous tissue.

(From Becker AE, Anderson RH [eds]: Cardiac Pathology: An Integrated Text and Colour Atlas. New York, Raven Press, 1983, p 4.3.)

Hemodynamics

• Schematic representation of left ventricular (LV), aortic, and left atrial (LA) pressures, showing normal relationships and alterations with mild and severe mitral stenosis (MS). Corresponding classic auscultatory signs of MS are shown at the bottom. Compared with mild MS, with severe MS the higher left atrial v wave causes earlier pressure crossover and earlier mitral valve (MV) opening, leading to a shorter time interval between aortic valve (AV) closure and the opening snap (OS). The higher left atrial end-diastolic pressure with severe MS also results in later closure of the mitral valve. With severe MS, the diastolic rumble becomes longer and there is accentuation of the pulmonic component (P2) of the second heart sound (S2) in relation to the aortic component (A2).

Classification of severity of MS

Mitral stenosis

Mild Moderate Severe

Mean Gradient* (mmHg)

<5 5-10 >10

Pulmonary artery systolic pressure (mmHg)

<30 30-50 >50

Valve area (cm2) >1.5 1.0-1.5 <1.0

*valve gradients are flow dependent and when used to assess severity of valve stenosis should be assessed with knowledge of cardiac output or forward flow across the valve.

Natural history of MSNatural history of 159 patients

with isolated mitral stenosis (solid blue line) or mitral regurgitation (solid purple line) who were not operated on (even though the operation was indicated) compared with patients treated with valve replacement for mitral stenosis (dashed blue line) or mitral regurgitation (dashed purple line). The expected survival rate in the absence of mitral valve disease is indicated by the upper curve (dashed black line).

(From Horstkotte D, Niehues R, Strauer BE: Pathomorphological aspects, aetiology, and natural history of acquired mitral valve stenosis. Eur Heart J 12[Suppl]:55-60, 1991.)

Echo in MS

Evaluation of MS by Echo

• Valve anatomy, mobility and calcification

• Mean trans-mitral pressure gradient

• 2D Echo mitral valve area (planimetry)

• Doppler pressure half-time area

• Pulmonary artery pressures (TR jet and IVC)

• Coexisting MR

MV Morphology by 2D EchoThe Wilkins Score

• Intended for predicting the likelihood of success of balloon valvulopasty

• Total valve score will be in the range of 0 to 16

• Scores ≤8 associated with an optimal outcome from percutaneous valvuloplasty

• Scores of ≥12 are associated with a poor outcome.

“Doming” of anterior leaflet

(From Bach DS: Rheumatic mitral stenosis. N Engl J Med 337:31, 1997.)

Mean trans-mitral pressure gradient by Doppler

• Simplified Bernoulli equation:

ΔP= 4 v2

• Measurement of the Velocity Time Integral of a continuous wave Doppler recording of the entire period of mitral inflow.

• Depends on transmitral flow rate

Pitfalls of Pressure Gradient

• Intercept angle between MS jet and ultrasound beam

• Beat-to-beat variability in AF

• Dependence on trans-mitral volume flow rate (i.e., exercise, MR, etc.)

2D Echo Mitral Valve Area

• Planimetry of short-axis of the MV orifice

• Tracing of the iner edge of the valve

• Validated by comparison with valve area at surgery

• Requires adequate image quality

Pitfalls of 2D Valve Area

• Image orientation

• Tomographic plane

• 2D gain settings

• Intra and inter-observer variability in planimetry of orifice

• Poor acoustic access

• Deformed valve anatomy after valvuloplasty

Doppler pressure half-time area

• The smaller the MV orifice, the slower the rate of pressure decline

• T1/2= time for the peak transmitral pressure to halve (in msecs)

• Empiric formula: MVA= 220/T1/2

• Affected by ventricular compliance and cardiac output

Pitfalls of Pressure Halftime

• Definition of Vmax and early diastolic deceleration slope

• Nonlinear early diastolic slope

• Sinus rhythm with a wave superimposed on early diastolic slope

• Influence of coexisting AI

• Changing LV and LA compliances esp. after commissurotomy

Common Echo Findings in MS

• Left atrial enlargement and thrombus

• Pulmonary hypertension

• Mitral regurgitation

• Coexisting valvular disease (aortic and/or tricuspid)

• Small LV, normal systolic function

FIN

Case 2-K.W.

• 43 y.o. M who is s/p closure of VSD at Ochsner Clinic at age 13

• Presented to clinic with increasing fatigue

• A 2D ECHO and a TEE are performed..

TEE

Case 2-K.W. cath

Case 3-P.S.

• 42 y.o. F with Ehlers-Danlos syndrome who is s/p closure of ASD at age 7

• More recently, she developed increasing dyspnea and fatigue

• She also has history of atrial fibrillation

• Patient undergoes TEE and cardiac catheterization

TEE

Case 3-P.S. LHC

Case 3-P.S.

• LHC: normal coronaries. AoP 110/65 LVEDP 22, LV-gram normal LV function, 3+MR

• RHC: No step-up of venous o2 saturation sugesting residual ASD. PCWP 6 PAP 22/7 RV 23/6

• CO thermodilution 5.63 L/min

• CI 2.76 L/min/m2

Case 3-P.S.

• Pt underwent mitral valve repair and modified maze procedure on 6/16 by Dr. Piggott

• At follow-up on 8/24, notable improvement of patient’s dyspnea on exertion is reported