Infective endocarditis and heart masses


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Infective endocarditis and heart masses

  2. 2. Infective Endocarditis
  3. 3. Introduction Infective endocarditis occurs primarily on cardiacvalves but can involve other endocardial surfaces orintracardiac devices Potentially fatal with 6 month mortality rate of 25 to30% The incidence of IE is higher in patients who havevalvular heart disease (rheumatic valve, bicuspidaortic valve, mitral valve prolapse, or prosthetic valve)or congenital heart disease and among intravenousdrug users Most commonly mitral and aortic valves are involvedbut involvement of right side of heart is notuncommon, especially in intravenous drug users
  4. 4.  Hydraulic features of the blood stream areimportant in the pathogenesis of endocarditis Associated with a high-pressure source(i.e., aorta, left ventricle) that drives blood at ahigh velocity through a narrow orifice(coarctation, PDA, VSD, AR or MR or obstructivehypertrophic cardiomyopathy) into a low-pressurechamberIntroductionRodbard S. Blood velocity and endocarditis. Circulation, 1963;27:18-28
  5. 5.  Since the 1st M-Mode echo observation of valvularvegetation in 1973, the role of echo in diagnosing IEhas grown in conjunction with improvement inresolution and technology including Dopplerechocardiography, color flow imaging, andtransesophageal echocardiography (TEE) Indeed the echo detection of vegetation is one of thetwo major diagnostic criteria for IEIntroductionAmerican Heart Journal, 1973;86:698-704
  6. 6.  Vegetation is an oscillating intracardiac mass ona valve or supporting structure or in the path ofregurgitation get or an iatrogenic device Can be linear, round, irregular or shaggy andfrequently show high frequency flutter oroscillationEchocardiographic Appearance
  7. 7. Echocardiographic Appearance
  8. 8.  Other associated findings Abcesses New partial dehiscence of prosthetic valve New valvular regurgitation Initial attachment to MV and TV is usually onatrial side An aortic vegetation usually start from ventricularsurfaceEchocardiographic Appearance
  9. 9.  The sensitivity of 2D echo for the detection ofvegetation depends on the size and location ofthe vegetation and echocardiographic windowused The sensitivity for detection of vegetation withTTE is 65 to 80% when size of vegetation <1cmand with TEE is 95% For prosthetic endocarditis the diagnostic yield ofTTE is especially poor, but the sensitivity of TEEis 90%Echocardiographic AppearanceJournal of the American College of Cardiology, 1989;14:631-38Journal of the American College of Cardiology, 1991;18:391-97
  10. 10.  The vegetation on the right side of the heart arelarger (mean diameter 17mm) than those on theleft side Vegetations frequently persist after successfulmedical treatment, however persistent vegetationare not independently associated with the latecomplicationEchocardiographic Appearance
  11. 11.  Complications arise from primarily from Vegetation embolization Destruction of valve or intracardiac structures Abcesses and subsequent haemodynamicdeterioration In the left sided valve endocarditis, the frequency ofclinical complications increased with the greatermobility and size of vegetation When vegetations were larger than 11 mm, 50% ormore of patients developed at least one complicationof infective endocarditis In patients with tricuspid valve endocarditis, PE is themost common complication 69%Complications
  12. 12.  Structural Cusp or leaflet rupture/flail Perforation Abscess Aneurysm Fistula Dehiscence of prostheticvalve Pericardial effusion (morefrequent with abscess) Embolization Systemic Cerebral Pulmonary Hemodynamiccompromise Valvular regurgitation Acute mitral regurgitation Acute aortic regurgitation Premature mitral valveclosure Restrictive mitral inflowpattern Valvular stenosis Shunt Congestive heart failureComplications
  13. 13.  When the endocardial surface is traumatized, aseries of events may lead to plateletdeposition, creating a nonsterile platelet fibrinthrombus Libmann sacks endocarditis: (Associated withAPLA) This condition usually involve mitral valve and isfound most commonly on the basal portion of MVbut it can extend to the cordal structure or papillarymuscles The lesions are difficult to see with TTENon-bacterial Thrombotic Endocarditis
  14. 14.  Young male Intravenous drug abuser Presented with fever, pedal edema and shortnessof breathCase
  15. 15. Vegetation on Prosthesis
  16. 16. Vegetation on Shunts
  17. 17. A metastatic tumor also can involve cardiacvalves and produce lesions similar to those inLibman-Sacks endocarditis. This is calledmarantic endocarditis and occurs most commonlywith Hodgkin disease and adenocarcinoma of thelung, pancreas, stomach, and colonMarantic Endocarditis
  18. 18.  Several limitations and pitfalls Other lesions of the valves, such as markedmyxomatous degeneration of the mitral valve,nonbacterial thrombotic endocarditis or tumor,thrombus attached to the valve (i.e., papilloma),may simulate or mask vegetations When a valve is sclerotic, calcified or prosthetic, itis more difficult to visualize a vegetation - TEEmay be useful Clinical presentation and lab data need to beincorporated into the interpretation of theechocardiographic findingsClinical Caveats
  20. 20.  Detection of a large intracardiac mass is animpressive experience for clinicalechocardiographers Some cardiac masses are suspected from theclinical presentation of the patient and other areincidental findings Occasionally, a normal structure or a variant of anormal structure may appear as an intracardiacmass Accurate diagnosis is crucial becausemisinterpretation may lead to an incorrectmanagement strategy, including an unnecessarysurgical procedureCardiac Masses
  21. 21.  Cardiac masses can be classified as Cardiac tumor Thrombus Vegetation Iatrogenic material Normal variant Extracardiac structure These masses usually can be differentiated bytheir size, shape, location, mobility andattachment site as well as by their clinicalpresentationCardiac Masses
  22. 22. Echo Indications in Cardiac Masses
  23. 23.  Although primary cardiac tumors usually arebenign, they can cause systemic symptoms,embolic events, malignant arrhythmias, chestpain, and heart failure So, it is recommended that cardiac tumors beremoved whenever possible They can be Benign Malignant Primary SecondaryCardiac Tumor
  24. 24. Tumor and Masses
  25. 25. Tumor and Masses
  26. 26.  Not all masses detected with echocardiographyare thrombus or intracardiac tumor The normal appearance of cardiac andextracardiac structures can be misinterpretedas an intracardiac mass…Normal Anatomic Varients
  27. 27. …Normal Anatomic Varients
  28. 28. …Normal Anatomic Varients
  29. 29. Cordae
  30. 30. Lipomatous Interatrial Septum
  31. 31. Moderator Band
  32. 32. Moderator Band
  33. 33. Reverberation Artefact
  34. 34. Papillary Muscle
  35. 35. Pacemaker Lead
  36. 36. Chiari Network
  37. 37. Lamble’s
  38. 38.  Myxoma is the most common cardiactumor, accounting for 20 to 30% of intracardiactumors LA is the most common location with attachmentsite at the atrial septum Typical M-mode and 2D echo appearance Other locations and attachment sites have beenobserved including RA, RV, LV and atrioventricularvalve Atypically located myxoma is usually familial -Carney Complex Familial atrial myxomas account for 7% of all atrialmyxomasMyxoma
  39. 39.  Atrial myxoma appear gelatinous and friable withoccasional central necrosis Embolic events are more common with a smallmyxoma These tumors can obstruct AV valve Yearly echo is indicated after resection ofmyxoma at for 5 yearsMyxoma
  40. 40.  Fibromas usually are located in the LV freewall, ventricular septum or at the apex It is well demarcated from surroundingmyocardium by multiple calcifications May grow in LV cavity and interfere with LV filling Potential problems resulting from a fibroma arecongestive heart failure and malignantarrhythmias When the tumor is located at the apex, thecondition may be misinterpreted by other imagingmodalities as apical hypertrophic cardiomyopathyCardiac Fibroma
  41. 41.  It is the most common cardiac tumor inchildren, particularly those with tuberous sclerosis Rhabdomyomas are often multiple, found inRV, RVOT and even in pulmonary artery May be diagnosed before birth with fetal echo Rhabdomyoma may regress spontaneously afterbirthCardiac Rhabdomyoma
  42. 42.  It is a benign intracardiac tumor, found in theendocardium These tumors are usually small (mean size 12into 9 mm) and have characteristic stippled edgewith shimmer or vibration at the tumor bloodinterface Most frequently papillary fibroelastomas arelocated on the aortic valve (either aortic orventricular surface), TV, PV, Septum, LV freewall, RVOT and LA 90% of patient have single tumor and other 10%have multiple tumorsPapillary Fibroelastoma
  43. 43.  Primary cardiac pheochromocytomas is very rarebut it has characteristic location, size and shape Found mostly in AV grove, well circumscribedand ovoid, ranging from 1.5 to 5.1 cm Common in female (mean age 38 years) Coronary angio shows that the tumor hascoronary neovascular blood supplyPheochromacytoma
  44. 44.  Malignant primary cardiac tumors include Angiosarcoma Rhabdomyosarcoma Myxosarcoma Osteosarcoma Fibrosarcoma Synovialsarcoma Angiosarcoma occur commonly in RA inconjuction with paricardial effusion Rhabdomyosarcoma and fibrosarcoma can occurany where in the heart Synovial sarcoma is rare and occurs in RAMalignant Tumors
  45. 45.  Frequently secondary malignant tumorsmetastasize fromlungs, breast, kidney, liver, melanoma, osteogenicsarcoma Whenever RA mass is detected, the IVC shouldbe scanned carefullySecondary tumor
  46. 46. Secondary tumor
  47. 47.  RA thrombus: Thrombi from lower extremity deep vein must gothrough RA to pulmonary circulation They are mobile, have a characteristic popcorn orsnake like appearance Almost always are associated with pulmonary embolismThrombus
  48. 48.  RV thrombusThrombus
  49. 49.  LA Thrombus: Common in mitral stenosis or atrial fibrillation Infrequently occurs as a paradoxical embolus from an RAthrombus passing through a patent foramen ovale TTE is limited in detecting thrombus in LAA In all patients, the LA appendage is visualized from atransesophageal windowThrombus
  50. 50.  LV thrombus Easily differentiated from a tumor because thethrombus is almost associated with akinetic todyskinetic myocardium underlying the thrombus Contrast echo can be very helpful in identifying andevaluating an apical mass/thrombusThrombus
  51. 51.  IVC CLOTThrombus
  52. 52. case Young female With chest pain
  53. 53. Another case
  54. 54. Take Home Message
  55. 55. Take Home Message
  56. 56. Take Home Message