Infective endocarditis and heart masses
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Infective endocarditis and heart masses

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    Infective endocarditis and heart masses Infective endocarditis and heart masses Presentation Transcript

    • Dr. Fuad FarooqINFECTIVE ENDOCARDITIS ANDHEART MASSES
    • Infective Endocarditis
    • 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
    •  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
    •  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
    •  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
    • Echocardiographic Appearance
    •  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
    •  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
    •  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
    •  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
    •  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
    •  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
    •  Young male Intravenous drug abuser Presented with fever, pedal edema and shortnessof breathCase
    • Vegetation on Prosthesis
    • Vegetation on Shunts
    • 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
    •  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
    • TUMORS AND MASSES
    •  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
    •  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
    • Echo Indications in Cardiac Masses
    •  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
    • Tumor and Masses
    • Tumor and Masses
    •  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
    • …Normal Anatomic Varients
    • …Normal Anatomic Varients
    • Cordae
    • Lipomatous Interatrial Septum
    • Moderator Band
    • Moderator Band
    • Reverberation Artefact
    • Papillary Muscle
    • Pacemaker Lead
    • Chiari Network
    • Lamble’s
    •  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
    •  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
    •  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
    •  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
    •  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
    •  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
    •  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
    •  Frequently secondary malignant tumorsmetastasize fromlungs, breast, kidney, liver, melanoma, osteogenicsarcoma Whenever RA mass is detected, the IVC shouldbe scanned carefullySecondary tumor
    • Secondary tumor
    •  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
    •  RV thrombusThrombus
    •  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
    •  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
    •  IVC CLOTThrombus
    • case Young female With chest pain
    • Another case
    • Take Home Message
    • Take Home Message
    • Take Home Message