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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.

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case presentation

Case Presentation

Federico Viganego, M.D.

1/19/07

case 1 h h
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..
case 1 h h 2d echo
Case 1-H.H. 2D ECHO
  • Image 38
  • Image 42
  • Images 60-66
  • Image 69-79
case 1 h h5
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..
case 1 h h16
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 h17
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
Cardiac Masses
  • Abnormal structure within or immediately adjacent to the heart

Three types of cardiac masses:

  • Tumor
  • Thrombus
  • Vegetation
cardiac mass echocardiography
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
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 structures right atrium
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
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
right sided thrombi
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

Risk of embolization
cardiac mass vs normal structures left atrium
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 structures left ventricle
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

Cardiac mass vs. normal structures
case 2 d j
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
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
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 cath37
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
mitral stenosis
Mitral Stenosis

Rheumatic 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
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
Classification of severity of MS

*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 ms
Natural history of MS

Natural 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.)

evaluation of ms by echo
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 echo the wilkins score
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
“Doming” of anterior leaflet

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

mean trans mitral pressure gradient by doppler
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
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
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
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
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
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
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
case 2 k w
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..
case 3 p s
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
case 3 p s61
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 s62
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