Vegetations, Variants, Devices and Artefacts Flashcards
What are vegetations?
- Infected mass attached to sites of endocardial injury or implanted intracardiac material
Where do vegetations form?
- Upstream of infected valves:
- Atrial surface of AV valves (MV&TV)
- Ventricular surface of semilunar valves (PV&AV)
Echo appearance of vegetations?
- Vegetation can appear as oscillating or non-oscillating mass
- Oscillating mass in patient with febrile illness and new heart murmur = likely IE
Texture of vegetation: likely vs unlikely?
- Likely: reflectance of myocardium (grey)
- Unlikely: hyper-reflective
Location of vegetation: likely vs unlikely?
- Likely: upstream of native valve
- Unlikely: downstream of native valve
Shape of vegetation: likely vs unlikely?
- Likely: irregular and lobulated
- Unlikely: filamentous or ‘stringy’, discrete nodule
Mobility of vegetation: likely vs unlikely?
- Likely: mobile, high frequency
- Unlikely: fixed and immobile
Accompanying abnormalities of vegetations: likely vs unlikely?
- Likely: regurgitation, abscess, fistula, valve aneurysm
- Unlikely: None
Normal LA variants that may be confused for a mass?
- Pectinate muscles
- “Q-tip”
Normal valve variants that may be confused for a mass?
Lambl’s excrescences (AV/PV)
Normal LV variants that may be confused for a mass?
- False tendons
- Aberrant papillary muscles
Normal pericardial variants that may be confused for a mass?
Epicardial fat
Normal RV variants that may be confused for a mass?
Moderator band
Normal RA variants that may be confused for a mass?
- Crista terminalis
- Eustachian ridge
- Eustachian valve
- Chiari network
Characteristics of LA pectinate muscles?
- 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
Echo appearance of LA pectinate muscles?
- 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
Characteristics of LA Q-Tip?
- 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
Characteristics of RA Crista Terminalis (CT)?
- Located at junction of trabeculated RAA and smooth muscle of RA
- C shaped: originates from IAS medially
Characteristics of Eustachian Ridge (ER)?
- Extension of crista terminalis
- Course across inferior border of RA
- Separates orifice of IVC from orifice of coronary sinus
Characteristics of Eustachian Valve (EV)?
- Remnant of foetal circulation
- Arises from orifice of IVC and attaches to IAS
Characteristics of Chiari Network?
- Fenestrated variant of the eustachian valve
- Appears as a ‘lace-like’ veil membrane
- More mobile and ‘whip-like’ compared to eustachian valve
Characteristics of RV Moderator Band?
- Aka septomarginal trabecula
- Prominent muscular trabeculation
- Traverses RV at apical level
- Connects IVS to anterior papillary muscle
- Helpful in differentiating RV from LV
Characteristics of LV Ventricular False Tendons?
- 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
False Tendons vs Thrombus
- Identification of echo-free space on each side of structure
- Constant motion over cardiac cycle
- Presence of normal ventricular wall motion adjacent to structure
= false tendons not thrombus
Characteristics of LV Aberrant Papillary Muscles?
- Displacement, mal positioning or accessory papillary muscles may mimic LV thrombus
- May be seen with HCM
- identified by chordal attachments of MV
Characteristics of Lambl’s Excrescences?
- 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)
Where is epicardial fat located?
Fat deposit between myocardium and visceral layer of pericardium
Where is pericardial fat located?
Situated outside visceral pericardium and external to parietal pericardium
Peripherally inserted central catheter (PICC) or port-a-cath (port) as seen with echo?
Catheter tip tends to sit within SVC and is sometimes seen extending into RA
PDA closure devices as seen with echo?
- Echo-bright, bulky devices seen on echo
- Best seen from high PSAX view
What is a watchman device?
- LAA occluder device
- Implanted in patients with non-valvular AF
- Reduce thromboembolic risk
Watchman device as seen on echo?
- Bulky echo-genetic area in LAA region
- Better seen with TOE
What can Amplatzer Closure Devices close?
- ASD/PFO
- VSD
- Paravalvular leak
What are mechanical circulatory support (MCS) devices?
- Surgically implanted LVAD (LV assist devices)
- Percutaneous impella (catheter based devices)
Which devices can be nidus for infection and thrombus?
- LVAD thrombus
- PPM vegetation
- Watchman thrombus
Types of artefact that result in “added” echoes?
- Mirror artefact
- Reverberation artefact
Types of artefact that mimic masses?
- Slice thickness artefact
- Range ambiguity artefact
- Near-field clutter artefact
What is slice thickness artefact?
- Slice thickness is width of transducer
- Anything detected within slice thickness will be compressed and displayed as one image
What is a figure-of-eight artefact and when is it seen?
- Type of slice thickness artefact
- Occurs with amplatzer devices
When may range ambiguity artefacts occur?
- 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
When do we have a high PRF?
- Shallower field of view + low attenuation structure (such as blood-filled cavities) = structure outside FOV displayed within FOV
What are near-field clutter artefacts?
- Type of reverberation artefact commonly seen in near field
- Reverberation due to interaction with chest wall structures
- Refraction from rib
How to overcome near-field clutter artefacts?
- Adjust probe position
- Move focus to apex
- Use a higher transducer frequency
- Try colour Doppler to define apex
- Use ultrasound enhancing agents
Artefact or real: characteristics that would suggest artefact?
- 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
