Case Presentation

1
Case Presentation

• Federico Viganego, M.D.
• 1/19/07

2
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..

3
Echocardiogram
4
Case 1-H.H. 2D ECHO

• Image 38
• Image 42
• Images 60-66
• Image 69-79

5
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..

6
MRI
7
MRI
8
MRI
9
MRI
10
MRI
11
MRI
12
MRI-CORONAL VIEW
13
MRI-SAGITTAL VIEW
14
MRI-SAGITTAL VIEW
15
MRI-SAGITTAL VIEW
16
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

17
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

18
Cardiac Masses

• Abnormal structure within or immediately adjacent
  to the heart
• Three types of cardiac masses
• Tumor
• Thrombus
• Vegetation

19
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

20
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

21
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

22
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

23
Chiari Network
24
Pacer Wire
25
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

26
Risk of embolization

• Higher
• Irregular shape
• Protruding in the cavity
• Mobile
• Seen in multiple projections

• Lower
• Flat
• Immobile
• Seen in single projections

27
Distingushing intracardiac masses
28
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

29
Cardiac mass vs. normal structuresLeft Ventricle

• Papillary muscles
• Left ventricular web (aberrant chordae)
• Prominent apical trabeculations
• Prominent mitral annular calcification

30
Cardiac mass vs. normal structures

• Right Ventricle
• Moderator band
• Papillary muscles
• Swan-Ganz catheter or pacer wire

• Aortic Valve
• Nodules of Arantius
• Lambls excrescenses
• Base of valve leaflet seen en face in diastole

31
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

32
Case 2-D.J. Echo

• Image 10
• Image 15
• Images 39-40 and 44
• Images 45-51
• Image 58

33
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-time1.5 cm2, mean gradient11 mmHg)
• Calcified aortic valve with moderate AS by
  continuity equation (AVA 1.4 cm2)
• Mild to moderate TR. Severe PHTN

34
Case 2-D.J. TEE
35
Case 2-D.J. TEE
36
Case 2-D.J. cath
37
Case 2-D.J. cath

• RH cath RA pressures 8 mmHg, RV 31/6, PAP 57/25,
  
• Simultaneous pressures PCWP 24 mmHg, LVEDP8-11
  mmHg, trans-mitral valve gradient 13-16 mmHg
• CO2.67 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

38
CASE 2-D.J.-2D ECHO recent
39
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.)
40
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).

41
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.
42
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 12Suppl55-60, 1991.)
43
Echo in MS
44
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

45
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.

46
Doming of anterior leaflet
(From Bach DS Rheumatic mitral stenosis. N Engl
J Med 33731, 1997.)
47
Mean trans-mitral pressure gradient by Doppler

• Simplified Bernoulli equation
• ?P 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

48
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.)

49
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

50
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

51
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

52
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

53
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

54
FIN
55
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..

56
TEE
57
Case 2-K.W. cath
58
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

59
TEE
60
Case 3-P.S. LHC
61
Case 3-P.S.

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

62
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
  patients dyspnea on exertion is reported