Vegetations, Variants, Devices and Artefacts

Question 1

What are vegetations?

Answer 1

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

Question 2

Where do vegetations form?

Answer 2

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

Question 3

Echo appearance of vegetations?

Answer 3

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

Question 4

Texture of vegetation: likely vs unlikely?

Answer 4

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

Question 5

Location of vegetation: likely vs unlikely?

Answer 5

• Likely: upstream of native valve
• Unlikely: downstream of native valve

Question 6

Shape of vegetation: likely vs unlikely?

Answer 6

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

Question 7

Mobility of vegetation: likely vs unlikely?

Answer 7

• Likely: mobile, high frequency
• Unlikely: fixed and immobile

Question 8

Accompanying abnormalities of vegetations: likely vs unlikely?

Answer 8

• Likely: regurgitation, abscess, fistula, valve aneurysm
• Unlikely: None

Question 9

Normal LA variants that may be confused for a mass?

Answer 9

• Pectinate muscles
• “Q-tip”

Question 10

Normal valve variants that may be confused for a mass?

Answer 10

Lambl’s excrescences (AV/PV)

Question 11

Normal LV variants that may be confused for a mass?

Answer 11

• False tendons
• Aberrant papillary muscles

Question 12

Normal pericardial variants that may be confused for a mass?

Answer 12

Epicardial fat

Question 13

Normal RV variants that may be confused for a mass?

Answer 13

Moderator band

Question 14

Normal RA variants that may be confused for a mass?

Answer 14

• Crista terminalis
• Eustachian ridge
• Eustachian valve
• Chiari network

Question 15

Characteristics of LA pectinate muscles?

Answer 15

• 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

Question 16

Echo appearance of LA pectinate muscles?

Answer 16

• 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

Question 17

Characteristics of LA Q-Tip?

Answer 17

• 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

Question 18

Characteristics of RA Crista Terminalis (CT)?

Answer 18

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

Question 19

Characteristics of Eustachian Ridge (ER)?

Answer 19

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

Question 20

Characteristics of Eustachian Valve (EV)?

Answer 20

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

Question 21

Characteristics of Chiari Network?

Answer 21

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

Question 22

Characteristics of RV Moderator Band?

Answer 22

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

Question 23

Characteristics of LV Ventricular False Tendons?

Answer 23

• 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

Question 24

False Tendons vs Thrombus

Answer 24

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

Question 25

Characteristics of LV Aberrant Papillary Muscles?

Answer 25

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

Question 26

Characteristics of Lambl's Excrescences?

Answer 26

- 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)

Question 27

Where is epicardial fat located?

Answer 27

Fat deposit between myocardium and visceral layer of pericardium

Question 28

Where is pericardial fat located?

Answer 28

Situated outside visceral pericardium and external to parietal pericardium

Question 29

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

Answer 29

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

Question 30

PDA closure devices as seen with echo?

Answer 30

- Echo-bright, bulky devices seen on echo - Best seen from high PSAX view

Question 30

What is a watchman device?

Answer 30

- LAA occluder device - Implanted in patients with non-valvular AF - Reduce thromboembolic risk

Question 31

Watchman device as seen on echo?

Answer 31

- Bulky echo-genetic area in LAA region - Better seen with TOE

Question 32

What can Amplatzer Closure Devices close?

Answer 32

1. ASD/PFO 2. VSD 3. Paravalvular leak

Question 33

What are mechanical circulatory support (MCS) devices?

Answer 33

- Surgically implanted LVAD (LV assist devices) - Percutaneous impella (catheter based devices)

Question 34

Which devices can be nidus for infection and thrombus?

Answer 34

- LVAD thrombus - PPM vegetation - Watchman thrombus

Question 35

Types of artefact that result in "added" echoes?

Answer 35

- Mirror artefact - Reverberation artefact

Question 36

Types of artefact that mimic masses?

Answer 36

- Slice thickness artefact - Range ambiguity artefact - Near-field clutter artefact

Question 37

What is slice thickness artefact?

Answer 37

- Slice thickness is width of transducer - Anything detected within slice thickness will be compressed and displayed as one image

Question 38

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

Answer 38

- Type of slice thickness artefact - Occurs with amplatzer devices

Question 39

When may range ambiguity artefacts occur?

Answer 39

- 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

Question 40

When do we have a high PRF?

Answer 40

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

Question 41

What are near-field clutter artefacts?

Answer 41

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

Question 42

How to overcome near-field clutter artefacts?

Answer 42

- Adjust probe position - Move focus to apex - Use a higher transducer frequency - Try colour Doppler to define apex - Use ultrasound enhancing agents

Question 43

Artefact or real: characteristics that would suggest artefact?

Answer 43

- 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