Case Presentation: 47 Year-old Male with Sudden Weakness,


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Case Presentation: 47 Year-old Male with Sudden Weakness,

  1. 1. Case Presentation Federico Viganego, M.D. 1/19/07
  2. 2. Case 1-H.H. <ul><li>61 y.o. M recently diagnosed with a right renal mass </li></ul><ul><li>Presented to the hospital with progressive dyspnea and worsening renal function </li></ul><ul><li>A 2D echo is ordered to evaluate the cause of dyspnea.. </li></ul>
  3. 3. Echocardiogram
  4. 4. Case 1-H.H. 2D ECHO <ul><li>Image 38 </li></ul><ul><li>Image 42 </li></ul><ul><li>Images 60-66 </li></ul><ul><li>Image 69-79 </li></ul>
  5. 5. Case 1-H.H. <ul><li>A mass is visualized in the R atrium. The mass is mobile, originates from the IVC, and is compatible with thrombus. </li></ul><ul><li>The RA mass measures 14 x 7 mm </li></ul><ul><li>A MRI of the abdomen is performed.. </li></ul>
  6. 6. MRI
  7. 7. MRI
  8. 8. MRI
  9. 9. MRI
  10. 10. MRI
  11. 11. MRI
  16. 16. Case 1-H.H. <ul><li>A large mass is identified in the right kidney </li></ul><ul><li>A large thrombus is seen in the R renal vein and within the infra-renal IVC extending to the level of iliac bifurcation </li></ul><ul><li>Thrombus is also seen within the IVC extending superiorly to the atrio-caval junction </li></ul>
  17. 17. Case 1-H.H. <ul><li>Pt undergoes embolization of the R renal artery on 12/22 and a repeat embolization of residual renal artery on 1/3 </li></ul><ul><li>On 1/11 pt underwent R radical nephrectomy, supradaphragmatic IVC thrombectomy, and splenectomy </li></ul>
  18. 18. Cardiac Masses <ul><li>Abnormal structure within or immediately adjacent to the heart </li></ul><ul><li>Three types of cardiac masses: </li></ul><ul><li>Tumor </li></ul><ul><li>Thrombus </li></ul><ul><li>Vegetation </li></ul>
  19. 19. Cardiac Mass-Echocardiography <ul><li>Pro : </li></ul><ul><li>Can provide both anatomic and physiologic information about the mass </li></ul><ul><li>Noninvasive, relatively inexpensive </li></ul><ul><li>Serial studies are feasible </li></ul><ul><li>Cons : </li></ul><ul><li>Suboptimal image quality in some patients </li></ul><ul><li>Relatively narrow field of view (vs.CT/MRI) </li></ul><ul><li>Mass versus ultrasound artifact </li></ul><ul><li>Mass versus normal structures </li></ul>
  20. 20. Diagnosis of Intracardiac Mass <ul><li>Excellent image quality </li></ul><ul><li>Identification in more than one acoustic window </li></ul><ul><li>Knowledge of normal structures, normal variants and post-op changes </li></ul><ul><li>Integration of other echo findings (i.e., rheumatic MS and LA thrombus) </li></ul><ul><li>Clinical data </li></ul>
  21. 21. Cardiac mass vs. normal structures Right Atrium <ul><li>Crista terminalis </li></ul><ul><li>Chiari network (Eustachian valve remnants) </li></ul><ul><li>Lipomatous hypertrophy of the interatrial septum </li></ul><ul><li>Trabeculation of the RAA </li></ul><ul><li>Atrial suture line (transplant) </li></ul><ul><li>Pacer wire, Swan-Ganz catheter, CVC, etc </li></ul>
  22. 22. Eustachian valve remnants <ul><li>Persistent portions of embryologic valves of sinus venosus </li></ul><ul><li>Junction of IVC/SVC with RA </li></ul><ul><li>Typically mobile </li></ul><ul><li>May be extensive -> Chiari network </li></ul><ul><li>Do not extend to cross the tricuspid valve </li></ul>
  23. 23. Chiari Network
  24. 24. Pacer Wire
  25. 25. Right-sided thrombi <ul><li>Rarely form in situ </li></ul><ul><li>Most commonly embolized from venous source </li></ul><ul><li>May be ‘entrapped’ in TV or RV structures </li></ul><ul><li>Indwelling catheters or pacer wires </li></ul><ul><li>Better characterized with TEE </li></ul><ul><li>If mobile, differential include Eustachian valve remnants </li></ul>
  26. 26. Risk of embolization <ul><li>Higher: </li></ul><ul><li>Irregular shape </li></ul><ul><li>Protruding in the cavity </li></ul><ul><li>Mobile </li></ul><ul><li>Seen in multiple projections </li></ul><ul><li>Lower: </li></ul><ul><li>Flat </li></ul><ul><li>Immobile </li></ul><ul><li>Seen in single projections </li></ul>
  27. 27. Distingushing intracardiac masses MV disease with LAE Fever, systemic signs of endocarditis, positive blood cultures LV systolic dysfn or segmental wma Valvular regurgitation usually present Intracardiac obstruction depending on site of tumor Underlying etiology usually evident Associated findings Irregular shape, attached to prox side (upstream) of the valve with motion independent from the valve Various: may be circumscribed or irregular Usually discrete and somewhat spherical or laminated against LV apex or LA wall Appearance LV (↓EF or segmental wma) Usually valvular Occasionally on ventricular wall or Chiari network LA (myxoma) Myocardium Pericardium Valves LA (esp. if enlarged or MV disease) Location Vegetation Tumor Thrombus Characteristic
  28. 28. Cardiac mass vs. normal structures Left Atrium <ul><li>Dilated coronary sinus (persistent L superior vena cava) </li></ul><ul><li>Raphe between L superior pulmonary vein and LAA </li></ul><ul><li>Atrial suture line (transplant) </li></ul><ul><li>Beam-width artifact from calcified aortic valve, AV prosthesis, etc. </li></ul><ul><li>Interatrial septal aneurysm </li></ul>
  29. 29. Cardiac mass vs. normal structures Left Ventricle <ul><li>Papillary muscles </li></ul><ul><li>Left ventricular web (aberrant chordae) </li></ul><ul><li>Prominent apical trabeculations </li></ul><ul><li>Prominent mitral annular calcification </li></ul>
  30. 30. Cardiac mass vs. normal structures <ul><li>Right Ventricle: </li></ul><ul><li>Moderator band </li></ul><ul><li>Papillary muscles </li></ul><ul><li>Swan-Ganz catheter or pacer wire </li></ul><ul><li>Aortic Valve: </li></ul><ul><li>Nodules of Arantius </li></ul><ul><li>Lambl’s excrescenses </li></ul><ul><li>Base of valve leaflet seen en face in diastole </li></ul>
  31. 31. Case 2-D.J. <ul><li>74 y.o. F presents with progressively worsening dyspnea and bilateral pleural effusions. Recently hospitalised for repeated syncopal episodes. </li></ul><ul><li>PMH: HTN, CAD, TIAs, Rheumatoid arthritis </li></ul><ul><li>MEDS: Methotrexate, Toprol, HCTZ, Lisinopril </li></ul><ul><li>SOCIAL: 40 pack-year tobacco hx </li></ul>
  32. 32. Case 2-D.J. Echo <ul><li>Image 10 </li></ul><ul><li>Image 15 </li></ul><ul><li>Images 39-40 and 44 </li></ul><ul><li>Images 45-51 </li></ul><ul><li>Image 58 </li></ul>
  33. 33. Case 2-D.J. 2D Echo <ul><li>Normal LV with normal to hyperdynamic systolic function </li></ul><ul><li>Mild LVH </li></ul><ul><li>Severe MAC. Moderate MS (MV area by pressure half-time=1.5 cm2, mean gradient=11 mmHg) </li></ul><ul><li>Calcified aortic valve with moderate AS by continuity equation (AVA 1.4 cm2) </li></ul><ul><li>Mild to moderate TR. Severe PHTN </li></ul>
  34. 34. Case 2-D.J. TEE
  35. 35. Case 2-D.J. TEE
  36. 36. Case 2-D.J. cath
  37. 37. Case 2-D.J. cath <ul><li>RH cath: RA pressures 8 mmHg, RV 31/6, PAP 57/25, </li></ul><ul><li>Simultaneous pressures: PCWP 24 mmHg, LVEDP=8-11 mmHg, trans-mitral valve gradient 13-16 mmHg </li></ul><ul><li>CO=2.67 L/min (thermodilution) </li></ul><ul><li>CI= 1.75 L/min/m2 </li></ul><ul><li>Coronary angio: LAD 60-70% mid, LCX minor lum irreg, RCA 50-60% prox-mid </li></ul><ul><li>LV-gram= normal LV filling and LV fn, MR2+ </li></ul><ul><li>Normal ascending aortogram </li></ul>
  38. 38. CASE 2-D.J.-2D ECHO recent
  39. 39. Mitral Stenosis <ul><li>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. </li></ul>(From Becker AE, Anderson RH [eds]: Cardiac Pathology: An Integrated Text and Colour Atlas. New York, Raven Press, 1983, p 4.3.)
  40. 40. Hemodynamics <ul><li>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). </li></ul>
  41. 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. <1.0 1.0-1.5 >1.5 Valve area (cm2) >50 30-50 <30 Pulmonary artery systolic pressure (mmHg) >10 5-10 <5 Mean Gradient* (mmHg) Severe Moderate Mild Mitral stenosis
  42. 42. Natural history of MS <ul><li>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). </li></ul>(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.)
  43. 43. Echo in MS
  44. 44. Evaluation of MS by Echo <ul><li>Valve anatomy, mobility and calcification </li></ul><ul><li>Mean trans-mitral pressure gradient </li></ul><ul><li>2D Echo mitral valve area (planimetry) </li></ul><ul><li>Doppler pressure half-time area </li></ul><ul><li>Pulmonary artery pressures (TR jet and IVC) </li></ul><ul><li>Coexisting MR </li></ul>
  45. 45. MV Morphology by 2D Echo The Wilkins Score <ul><li>Intended for predicting the likelihood of success of balloon valvulopasty </li></ul><ul><li>Total valve score will be in the range of 0 to 16 </li></ul><ul><li>Scores ≤8 associated with an optimal outcome from percutaneous valvuloplasty </li></ul><ul><li>Scores of ≥12 are associated with a poor outcome. </li></ul>
  46. 46. “ Doming” of anterior leaflet (From Bach DS: Rheumatic mitral stenosis. N Engl J Med 337:31, 1997.)
  47. 47. Mean trans-mitral pressure gradient by Doppler <ul><li>Simplified Bernoulli equation: </li></ul><ul><li>Δ P = 4 v 2 </li></ul><ul><li>Measurement of the Velocity Time Integral of a continuous wave Doppler recording of the entire period of mitral inflow. </li></ul><ul><li>Depends on transmitral flow rate </li></ul>
  48. 48. Pitfalls of Pressure Gradient <ul><li>Intercept angle between MS jet and ultrasound beam </li></ul><ul><li>Beat-to-beat variability in AF </li></ul><ul><li>Dependence on trans-mitral volume flow rate (i.e., exercise, MR, etc.) </li></ul>
  49. 49. 2D Echo Mitral Valve Area <ul><li>Planimetry of short-axis of the MV orifice </li></ul><ul><li>Tracing of the iner edge of the valve </li></ul><ul><li>Validated by comparison with valve area at surgery </li></ul><ul><li>Requires adequate image quality </li></ul>
  50. 50. Pitfalls of 2D Valve Area <ul><li>Image orientation </li></ul><ul><li>Tomographic plane </li></ul><ul><li>2D gain settings </li></ul><ul><li>Intra and inter-observer variability in planimetry of orifice </li></ul><ul><li>Poor acoustic access </li></ul><ul><li>Deformed valve anatomy after valvuloplasty </li></ul>
  51. 51. Doppler pressure half-time area <ul><li>The smaller the MV orifice, the slower the rate of pressure decline </li></ul><ul><li>T 1/2 = time for the peak transmitral pressure to halve (in msecs) </li></ul><ul><li>Empiric formula: </li></ul><ul><li>MVA= 220/T 1/2 </li></ul><ul><li>Affected by ventricular compliance and cardiac output </li></ul>
  52. 52. Pitfalls of Pressure Halftime <ul><li>Definition of V max and early diastolic deceleration slope </li></ul><ul><li>Nonlinear early diastolic slope </li></ul><ul><li>Sinus rhythm with a wave superimposed on early diastolic slope </li></ul><ul><li>Influence of coexisting AI </li></ul><ul><li>Changing LV and LA compliances esp. after commissurotomy </li></ul>
  53. 53. Common Echo Findings in MS <ul><li>Left atrial enlargement and thrombus </li></ul><ul><li>Pulmonary hypertension </li></ul><ul><li>Mitral regurgitation </li></ul><ul><li>Coexisting valvular disease (aortic and/or tricuspid) </li></ul><ul><li>Small LV, normal systolic function </li></ul>
  54. 54. FIN
  55. 55. Case 2-K.W. <ul><li>43 y.o. M who is s/p closure of VSD at Ochsner Clinic at age 13 </li></ul><ul><li>Presented to clinic with increasing fatigue </li></ul><ul><li>A 2D ECHO and a TEE are performed.. </li></ul>
  56. 56. TEE
  57. 57. Case 2-K.W. cath
  58. 58. Case 3-P.S. <ul><li>42 y.o. F with Ehlers-Danlos syndrome who is s/p closure of ASD at age 7 </li></ul><ul><li>More recently, she developed increasing dyspnea and fatigue </li></ul><ul><li>She also has history of atrial fibrillation </li></ul><ul><li>Patient undergoes TEE and cardiac catheterization </li></ul>
  59. 59. TEE
  60. 60. Case 3-P.S. LHC
  61. 61. Case 3-P.S. <ul><li>LHC: normal coronaries. AoP 110/65 LVEDP 22, LV-gram normal LV function, 3+MR </li></ul><ul><li>RHC: No step-up of venous o2 saturation sugesting residual ASD. PCWP 6 PAP 22/7 RV 23/6 </li></ul><ul><li>CO thermodilution 5.63 L/min </li></ul><ul><li>CI 2.76 L/min/m2 </li></ul>
  62. 62. Case 3-P.S. <ul><li>Pt underwent mitral valve repair and modified maze procedure on 6/16 by Dr. Piggott </li></ul><ul><li>At follow-up on 8/24, notable improvement of patient’s dyspnea on exertion is reported </li></ul>