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S4 W4 Cardiac Masses > Vegetations, Variants, Devices and Artefacts > Flashcards

Vegetations, Variants, Devices and Artefacts Flashcards

1
Q

What are vegetations?

A
  • Infected mass attached to sites of endocardial injury or implanted intracardiac material
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2
Q

Where do vegetations form?

A
  • Upstream of infected valves:
  • Atrial surface of AV valves (MV&TV)
  • Ventricular surface of semilunar valves (PV&AV)
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3
Q

Echo appearance of vegetations?

A
  • Vegetation can appear as oscillating or non-oscillating mass
  • Oscillating mass in patient with febrile illness and new heart murmur = likely IE
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4
Q

Texture of vegetation: likely vs unlikely?

A
  • Likely: reflectance of myocardium (grey)
  • Unlikely: hyper-reflective
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5
Q

Location of vegetation: likely vs unlikely?

A
  • Likely: upstream of native valve
  • Unlikely: downstream of native valve
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6
Q

Shape of vegetation: likely vs unlikely?

A
  • Likely: irregular and lobulated
  • Unlikely: filamentous or ‘stringy’, discrete nodule
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7
Q

Mobility of vegetation: likely vs unlikely?

A
  • Likely: mobile, high frequency
  • Unlikely: fixed and immobile
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8
Q

Accompanying abnormalities of vegetations: likely vs unlikely?

A
  • Likely: regurgitation, abscess, fistula, valve aneurysm
  • Unlikely: None
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9
Q

Normal LA variants that may be confused for a mass?

A
  • Pectinate muscles
  • “Q-tip”
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10
Q

Normal valve variants that may be confused for a mass?

A

Lambl’s excrescences (AV/PV)

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11
Q

Normal LV variants that may be confused for a mass?

A
  • False tendons
  • Aberrant papillary muscles
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12
Q

Normal pericardial variants that may be confused for a mass?

A

Epicardial fat

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13
Q

Normal RV variants that may be confused for a mass?

A

Moderator band

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14
Q

Normal RA variants that may be confused for a mass?

A
  • Crista terminalis
  • Eustachian ridge
  • Eustachian valve
  • Chiari network
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15
Q

Characteristics of LA pectinate muscles?

A
  • Prominent parallel ridges of atrial muscle within the atrial appendages
  • “Pectinate” = having projections resembling teeth of a comb
  • More prominent in LAA than RAA
  • May mimic LAA thrombus
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16
Q

Echo appearance of LA pectinate muscles?

A
  • Projections = pectinate muscles
  • Parallel, ridge-like appearance
  • Small size and absence of independent mobility
  • Pectinate muscles move with LA wall end not independent of it
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17
Q

Characteristics of LA Q-Tip?

A
  • Bulbous fold in LA wall separating orifice of LUPV from LAA
  • Q-tip = resembling q-tip of a cotton bad
  • Aka Coumadin ridge or Warfarin ridge
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18
Q

Characteristics of RA Crista Terminalis (CT)?

A
  • Located at junction of trabeculated RAA and smooth muscle of RA
  • C shaped: originates from IAS medially
19
Q

Characteristics of Eustachian Ridge (ER)?

A
  • Extension of crista terminalis
  • Course across inferior border of RA
  • Separates orifice of IVC from orifice of coronary sinus
20
Q

Characteristics of Eustachian Valve (EV)?

A
  • Remnant of foetal circulation
  • Arises from orifice of IVC and attaches to IAS
21
Q

Characteristics of Chiari Network?

A
  • Fenestrated variant of the eustachian valve
  • Appears as a ‘lace-like’ veil membrane
  • More mobile and ‘whip-like’ compared to eustachian valve
22
Q

Characteristics of RV Moderator Band?

A
  • Aka septomarginal trabecula
  • Prominent muscular trabeculation
  • Traverses RV at apical level
  • Connects IVS to anterior papillary muscle
  • Helpful in differentiating RV from LV
23
Q

Characteristics of LV Ventricular False Tendons?

A
  • Aka pseudo-tendons, aberrant bands, accessory chords or heart strings
  • Multiple or single fibrous structures that traverse the LV cavity
  • Pass between:
    a. pap muscle and IVC
    b. two pap muscles
    c. LV free wall to IVS
    d. two points of LV free wall
24
Q

False Tendons vs Thrombus

A
  1. Identification of echo-free space on each side of structure
  2. Constant motion over cardiac cycle
  3. Presence of normal ventricular wall motion adjacent to structure
    = false tendons not thrombus
25
Q

Characteristics of LV Aberrant Papillary Muscles?

A
  • Displacement, mal positioning or accessory papillary muscles may mimic LV thrombus
  • May be seen with HCM
  • identified by chordal attachments of MV
26
Q

Characteristics of Lambl’s Excrescences?

A
  • Fine, filamentous, mobile strands or fronds along line of valve closure
  • Ventricular size of AV and PV, and on atrial side of MV and TV
  • Thin, elongated and frequently multiple
  • May be ‘giant’ (occur when multiple adjacent excrescences adhere to one another)
27
Q

Where is epicardial fat located?

A

Fat deposit between myocardium and visceral layer of pericardium

28
Q

Where is pericardial fat located?

A

Situated outside visceral pericardium and external to parietal pericardium

29
Q

Peripherally inserted central catheter (PICC) or port-a-cath (port) as seen with echo?

A

Catheter tip tends to sit within SVC and is sometimes seen extending into RA

30
Q

PDA closure devices as seen with echo?

A
  • Echo-bright, bulky devices seen on echo
  • Best seen from high PSAX view
30
Q

What is a watchman device?

A
  • LAA occluder device
  • Implanted in patients with non-valvular AF
  • Reduce thromboembolic risk
31
Q

Watchman device as seen on echo?

A
  • Bulky echo-genetic area in LAA region
  • Better seen with TOE
32
Q

What can Amplatzer Closure Devices close?

A
  1. ASD/PFO
  2. VSD
  3. Paravalvular leak
33
Q

What are mechanical circulatory support (MCS) devices?

A
  • Surgically implanted LVAD (LV assist devices)
  • Percutaneous impella (catheter based devices)
34
Q

Which devices can be nidus for infection and thrombus?

A
  • LVAD thrombus
  • PPM vegetation
  • Watchman thrombus
35
Q

Types of artefact that result in “added” echoes?

A
  • Mirror artefact
  • Reverberation artefact
36
Q

Types of artefact that mimic masses?

A
  • Slice thickness artefact
  • Range ambiguity artefact
  • Near-field clutter artefact
37
Q

What is slice thickness artefact?

A
  • Slice thickness is width of transducer
  • Anything detected within slice thickness will be compressed and displayed as one image
38
Q

What is a figure-of-eight artefact and when is it seen?

A
  • Type of slice thickness artefact
  • Occurs with amplatzer devices
39
Q

When may range ambiguity artefacts occur?

A
  • May occur with high PRF
  • 2nd pulse emitted before signal from 1st pulse returns
  • Machine assumes signal returning from 1st pulse originates from 2nd pulse = signals will be placed too close to the transducer
40
Q

When do we have a high PRF?

A
  • Shallower field of view + low attenuation structure (such as blood-filled cavities) = structure outside FOV displayed within FOV
41
Q

What are near-field clutter artefacts?

A
  • Type of reverberation artefact commonly seen in near field
  • Reverberation due to interaction with chest wall structures
  • Refraction from rib
42
Q

How to overcome near-field clutter artefacts?

A
  • Adjust probe position
  • Move focus to apex
  • Use a higher transducer frequency
  • Try colour Doppler to define apex
  • Use ultrasound enhancing agents
43
Q

Artefact or real: characteristics that would suggest artefact?

A
  • Artefacts are non-anatomical
  • Artefacts cross tissue planes and organ boundaries
  • Artefacts may have motion separate from the heart
  • Artefacts usually not seen when viewed from multiple orthogonal windows
  • May be seen from study to study
  • Artefact only seen in 1 plane, real seen in > 1 plane

S4 W4 Cardiac Masses (2 decks)

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