Download Echocardiographic recognition and implications of

DIAGNOSTIC METHODS
ECHOCARDIOGRAPHY
Echocardiographic recognition and implications of
ventricular hypertrophic trabeculations and
aberrant bands
ANDRE KEREN, M.D., MARGARET E. BILLINGHAM, M.B., B.S.,
AND
RICHARD L. Popp, M.D.
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ABSTRACT The accuracy of two-dimensional echocardiography in the recognition of aberrant
ventricular bands and pathologic trabeculations (hypertrophic, fibrotic, or both) was assessed in 35
patients who underwent cardiac transplantation and pathologic examination. At pathologic study the
prevalence of specific intracavitary structures ranged from 28% to 43%. Left ventricular thrombi were
found in 12 patients (34%) and right ventricular thrombi in three (9%). Echocardiography accurately
defined left ventricular aberrant bands and left ventricular thickened or fibrotic trabeculations. Bands,
trabeculations, and thrombi each showed characteristic echocardiographic patterns. In the right ventricle, these structures were recognized, but accurate discrimination among them was not possible by
echocardiography. Aberrant bands and pathologic trabeculations mimicked or obscured fresh or organized thrombi in three patients on two-dimensional echocardiography. Left ventricular longitudinal
bands and pathologic right ventricular trabeculations obscured the interventricular septal border in four
patients; the presence of these abnormalities could lead to the erroneous diagnosis of asymmetric septal
hypertrophy on M mode echocardiography. By expressing the accuracy of two-dimensional echocardiography in the recognition of left ventricular anomalous bands, our results support the feasibility of
prospective studies to clarify their clinical significance.
Circulation 70, No. 5, 836-842, 1984.
LEFT AND RIGHT ventricular aberrant bands have
been noted as incidental findings at autopsy. 14Recently left ventricular aberrant bands have been recognized
in vivo by means of M mode and two-dimensional
echocardiography.f-10 In these initial reports the authors recognized left ventricular anomalous bands as
potential sources of echocardiographic diagnostic error
because they could mimic more important pathologic
entities.6, 7. l' The entities most frequently considered in the differential diagnoses were subaortic membrane, aortic or mitral valve vegetation, flail aortic or
mitral valve, pedunculated thrombi or tumors, and aneurysm of the sinus of Valsalva. The prevalence of
aberrant left ventricular bands, as recognized by echocardiography, ranges from 0.5% to 50%.6-10 In the
approximately 200 cases of aberrant bands reported,
pathologic confirmation of the echocardiographic findFrom the Departments of Medicine and Pathology. Stanford University School of Medicine, Stanford.
Supported in part by the Heiden Israeli Fellowship and Fogarty
Fellowship Grant F05 TWO 3416-01-B 1 National Institutes of Health
(A. K.).
Address for correspondence: Richard L. Popp, M.D., Cardiology
Division, Stanford University Medical Center. Stanford. CA 94305.
Received July 16, 1984; accepted Aug. 2, 1984.
836
ings was available in only four cases.-'- Thus the
reliability of two-dimensional echocardiography for
recognizing left ventricular aberrant bands has not
been established.
Although frequently recognized in everyday echocardiographic practice, right ventricular aberrant
bands and hypertrophic ventricular trabeculations have
not been systematically studied and their two-dimensional echocardiographic characteristics have not been
described.
The objectives of this study were (1) to assess the
reliability of two-dimensional echocardiography in defining left ventricular and right ventricular aberrant
bands and hypertrophic trabeculations and (2) to evaluate objectively the differential diagnostic difficulties
that may be encountered in the presence of these cavitary abnormalities. In this study we correlated the
echocardiographic and pathologic findings in patients
who underwent cardiac transplantation.
Methods
Materials. We reviewed the preoperative two-dimensional
echocardiograms and postoperative pathologic findings in the
original hearts of 35 patients who underwent cardiac transplantation at our institution. We included in the study only wellCIRCULATION
DIAGNOSTIC METHODS-ECHOCARDIOGRAPHY
TABLE 1
Accuracy of echocardiography in defining thickened ventricular trabeculations, aberrant bands, and thrombi
Thick trabeculae
Left ventricle
Right ventricle
Aberrant bands
Left ventricle
Right ventricle
Thrombi
Left ventricle
Sensitivity
Specificity
Positive
predictive
accuracy
(%)
(%)
(%)
(%)
80 (12/15)
60 (6/10)
85 (17/20)
72 (18/25)
80 (12/15)
46 (6/13)
85 (17/20)
81 (18/22)
85 (11/13)
50 (5/10)
82 (18/22)
72 (18/25)
73 (11/15)
38 (5/13)
90 (18/20)
77 (17/22)
67 (8/12)
87 (20/23)
73 (8/11)
83 (20/24)
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preserved hearts suitable for renewed analysis. Two patients
were excluded because of inadequate echocardiograms.
The ages of the patients at the time of heart transplantation
ranged from 15 to 51 years (mean 38). There were 12 female
and 23 male patients with either ischemic heart disease (n = 13)
or congestive cardiomyopathy (n = 22).
Pathologic data. The original pathologic reports were reviewed and the 35 hearts were reexamined by an experienced
pathologist (M. E. B.) who was blinded to the results of echocardiographic analysis. Aberrant ventricular bands were defined
as stringlike structures with free intracavitary courses, unrelated
to the atrioventricular valves, and connected to papillary muscles, ventricular walls, or both.3 This designation did not include the moderator band, which originates in the right ventricular septal wall from the trabecula septomarginalis and runs an
oblique course to the anterior papillary muscle.' 2. 13 The position, orientation, and points of insertion of the aberrant bands
were recorded.
Hypertrophy of the ventricular trabeculations was defined
qualitatively, since there are no data available for the range of
normal trabecular size. In this evaluation deviations from the
normal trabecular pattern in the left ventricle and right ventricle
were considered.'3 For this study a trabeculation differed from
an aberrant band by the lack of a free intracavitary course in the
former.
The heart specimens were also inspected for presence of
intracavitary anomalies such as endocardial fibrosis, ventricular
or valvular masses, and mural thrombi.
Echocardiography. Two-dimensional echocardiographic
studies were performed 2 to 160 days (64 + 50) before surgery
with a Hewlett Packard model 77020A imaging system and a
2.5 or 3.5 MHz medium or short-focused transducer. All studies
included at least the standard parasternal, apical, and subcostal
views.'4 Echocardiograms were interpreted independently by
two observers.
The echocardiographic diagnosis of aberrant ventricular band
was made with the observation of a stringlike structure with free
cavitary course, unrelated to the atrioventricular valves, and
connected to papillary muscles, left ventricular free walls, or
both. The insertion points and orientation of the bands in the
ventricular cavity were recorded. We also tried to define abnormal trabecular patterns qualitatively as hypertrophic (large,
with amplitude similar to myocardium), fibrotic (high intentisy
relative to myocardium), or both. Intracavitary masses such as
thrombi or valvular vegetations were noted. The accuracy of
two-dimensional echocardiography in defining right and left
ventricular intracavitary structures was expressed by calculating
sensitivity, specificity, and predictive accuracy.
Vol. 70, No. 5, November 1984
Negative
predictive
accuracy
Results
Pathologic data. From the 35 hearts examined, thickened trabeculae were recognized in the right ventricle
in 10 (28%) and in the left ventricle in 15 (43%) cases.
Aberrant bands were found in the right ventricle in 10
hearts (28%) and in the left ventricle in 13 (37%). Left
ventricular thrombi were found in 12 hearts (34%) and
right ventricular thrombi in three (9%). All patients
with right ventricular thrombi also had left ventricular
thrombi. Healed aortic valve vegetations were found in
two cases, and myxomatous degeneration of the mitral
valve was found in one.
Echocardiography. Data illustrating the accuracy of
two-dimensional echocardiography in defining thickened ventricular trabeculations, aberrant ventricular
bands, and left ventricular thrombi are displayed in
table 1.
Thickened ventricular trabeculations. We classified
thickened ventricular trabeculations as hypertrophic,
fibrotic, or both (figures 1 and 2). Hypertrophic trabeculations appeared as intracavitary endocardial prominences in the parastemal short-axis or standard apical
views (figures 1, A, and 2, A). In the hearts with
fibrotic trabeculations the endocardial surface appeared flat on standard echocardiographic views. In
the angled apical four-chamber view, however, highlighted randomly oriented linear structures with an interconnected or "honeycomb" appearance were found
(figures 1, B, and 2, B). In hearts with both thickened
and fibrotic trabeculations the echocardiogram showed
a combination of the above findings (figures 1, C, and
2, C).
In the right ventricle hypertrophic trabeculations
were less accurately defined (table 1). Both hypertrophic and fibrotic trabeculations appeared either as
thick linear structures (figure 1) or randomly oriented
structures with "honeycomb" appearance (figure 3).
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KEREN et al.
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FIGURE 1. Types of proninent left ventricular trabeculations on echocardiography as secn in the angled apical four-chamber
view (lpper rowl ) and parasternal short-axis view (lowe;t .zoi ). A, Hypertrophic trabeculations. B, Fibrotic trabeculations. C,
Hypertrophic and fhbrotic trabeculations. Note the similarity of the honeycomb' pattern in B and C (ioppcetr -zoo) bult the different
appearance of the endocardial surface in the shoirtaxis viewxs. For further detalils see text. ct
chordace tendineac: IVS =
interventricular septuim; LA = left atrium. LV - left ventricle: pm papillary imiuscle; RA = right atrium, Tr = trabecula=
=
tions.
In two hearts hypertrophic and fibrotic right ventricular trabeculations obscured the septal border on twodimensional and M mode echocardiograms.
Ventricular aberranit bands. Left ventricular aberrant
bands were accurately defined by echocardiography
(table 1). The 19 bands found in 13 hearts at pathologic
examination followed a transverse (six bands), longi-
tudinal (six bands), or sagittal plane (seven bands).
Transverse bands were best recognized either in a parasternal short-axis view or an apical four-chamber view
(figure 4). Longitudinal bands were best visualized in a
parasternal or apical long-axis view (figure 5). Longitudinal bands were easily recognized on two-dimensional echocardiography, but they were interpreted as
the left septal border on M mode studies in two cases.
The echocardiographic recognition of the sagittal
bands was more difficult. These bands usually appeared in the apical four-chamber view as discrete
spots moving with the cardiac cycle. Rotating the
transducer into an apical two-chamber or long-axis
plane usually permitted the length and orientation of
the sagittal bands to be appreciated (figure 6). Three of
the four false-positive echocardiographic diagnoses of
838
left ventricular bands (table 1) were associated with
prominent apical trabeculations at pathologic examination (figure 5) and an organized apical mural thrombus
was present in the fourth case.
Right ventricular bands were usually located in the
distal third of the ventricle (figures 3 and 7). Prominent
trabeculations in this area made separate recognition of
many right ventricular bands difficult (table 1). When
aberrant bands and pathologic trabeculations were
considered together, echocardiography was also accurate in recognition of intracavitary structures of the
right ventricle. With this approach, echocardiographic
sensitivity was 72%, specificity was 92%, positive
predictive accuracy was 80%, and negative predictive
accuracy was 88%.
Ventrwiclar ;naaasses. Data illustrating the accuracy of
echocardiography in defining left ventricular thrombi
in these patients is summarized in table 1. Six of the
seven patients with left ventricular thrombi and no
other intracavitary abnormalities were correctly recognized. A correct diagnosis of thrombus was made in
only two of five hearts with left ventricular thrombi
associated with either pathologic trabeculations or abCIRCULATION
DIAGNOSTIC METHODS-ECHOCARDLOGRAPHY
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FIGURE 2. Pathologic specimens fromii the three patients whose echocardiograms are represented in figure 1, showing
hypertrophic (A), fibrotic (B), and hypertrophic and fibrotic (C) trabeculationis. ALW = anterolateral wall; laa = left atrial
appendix; MV mitral valve; PW = posterior wall. Other abbreviations as in figure 1. The specimens are oriented with the apex
at the top of each panel to match the echocardiographic apical view.
errant bands. Two of three cases of right ventricular
thrombi were correctly recognized by echocardiography. In the third case fibrotic trabeculae obscured the
apical thrombi (figure 3).
As
~t pex
Tr
FS
.
2tsm
0
iS¢E
....... e-S|Ai
se
FIGURE 3. Apical four-chanmber echocardiographic views. A, Moderator band (mb) and aberrant band (b) in the right ventricle (RV). B, A
different transducer angulation reveals the right-sided 'honeycomb"
trabecular pattern that obscured the presence of apical thrombus (Th).
The apical masses were diagnosed only retrospectively after their recognition at pathologic examination (C). apm = anterior papillary muscle;
tsm = trabecula septomarginalis; TV
tricuspid valve.
=
Vol. 70, No. 5, November 1984
Discussion
The echocardiographic recognition of the cavitary
structures studied here may have little clinical significance per se, but these abnormalities may be important because of their potential to be mistaken for
more important pathologic entities.6 7. itt Nishimura
et al.6 and others7 10 1i hypothesized that difficulties
may be encountered in differentiating left ventricular
outflow structures from aberrant bands. Asinger et al.'
described two patients in whom the false-positive
echocardiographic diagnosis of left ventricular mural
thrombus could be made in the presence of an apical
aberrant band or a thick trabecula.
We studied a highly selected patient population to
correlate echocardiographic and pathologic findings.
This group of cardiac transplant candidates showed a
high prevalence of left and right ventricular aberrant
bands, pathologic trabeculations, and left ventricular
thrombi. On the basis of our experience with these
patients, we believe that by means of modern twodimensional echocardiographic instruments, aberrant
bands situated in the left ventricular outflow tract can
usually be accurately distinguished from the structures
cited by other investigators.6 7 10 ii
Our results confirm the previous observation5 that
the most important task is to differentiate these intracavitary structures from ventricular thrombi. The ac839
KEREN et al.
A
d.iastole
sys
curacy of echocardiographic diagnosis of left or right
ventricular thrombi was poor in cases with additional
intracavitary abnormalities. The seven incorrect diagnoses of left ventricular thrombi were associated
with aberrant bands or prominent trabeculations in
three instances. Fibrotic trabeculations obscured multiple apical right ventricular thrombi in another case
(figure 3).
Comparison of pathologic and echocardiographic
findings demonstrated that besides aberrant bands and
thick trabeculae,j fibrotic trabeculae may also play a
tote
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FIGURE 4. Transverse left ventriculai- aberrant band (b) recognized
in the parastemal short-axis view (A). Note lack of change in the shape
of the band from diastole to systole secondary to poor ventricular contractility. B, The same findings at pathologic examination. Abbreviations as in previous figures.
X~ ~ ~ ~~~~~~~~~~~~~~~~~~~.a
Tr
5
FIGURE 5. Longitudinal left ventricular aberrant hand (b) and sinele
apical trabeculation (Tr) seen in the apical long-axis view (A), apical
two-chamber view (B), and at pathologic examination (C). The apical
trabeculation was diagnosed erroneously as a second aberrant band by
echocardiography. Abbreviations as in previous figures.
840
FIGURE 6. Sagittal left ventricular band and left ventricular thrombi
detected in the apical four-chamber view (A and B) and apical long-axis
view (C and D), with pathologic findings (E). This patient also had a
right ventricular thrombus and an aberrant band (figure 3). Note the
variable location and appearance of the left ventricular band in different
views (A, B, and C) and in the same view as the heart shifts position
during the cardiac cycle (C and D). Abbreviations as in previous figures.
CIRCULATION
DIAGNOSTIC METHODS-ECHOCARDIOGRAPHY
FIGURE 8. Differentiation of these prominent apical trabeculations
(arrows) from thrombi is aided by rotation and angulation of the transducer in the apical views. For further details. see text. PrV prosthetic
valve. Other abbreviations as in previous figures.
=
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structures was common. In addition to imaging the
area of interest from different echocardiographic windows,5 it was useful if several views were obtained
from the same position. By rotating the transducer or
FIGURE 7. Aberrant right ventricular band (b) connecting the anterior (apm) and posterior (ppm) papillary muscles as recognized in the
parasternal short-axis (A) and long-axis view (B). The lack of prominent
trabecular pattern found at pathologic examination (C) eased the recognition of the band in this case. PE pericardial effusion. Abbreviations
as in previous hlgures.
major role in the echocardiographic misdiagnosis of
ventricular thrombi (figures 1 and 3); however, they
have a "honeycombed" echocardiographic appearance, made up of randomly oriented linear reflectors.
The diagnosis of thrombus in these cases can be made
only by demonstrating an echo-dense mass aligned
with the ventricular wall, which preserves its shape
and position in spite of changes in transducer angulation or position. However, relatively small thrombi
may be overlooked in patients with fibrotic trabeculations.
In patients with aberrant bands or a solitary prominent trabecula (figure 5), our experience supports previous observations5 of echocardiographic differentiation of these structures from thrombi. The diagnosis
of aberrant band or thick trabecula should be favored in
the presence of an echo-free space on each side of the
structure, constant motion pattern of the structure with
the cardiac cycle, and normal wall motion adjacent to
the mass. In these cardiac transplant recipients, akinesis or hypokinesis of the ventricular wall near these
Vol. 70, No. 5, November 1984
changing its angulation, the echocardiographer was
able to align the imaging plane with the intracavitary
structure. The echo-free space on both sides of the
structure thus became apparent (figure 8). However,
the cavitary edge of a fresh thrombus may give a similar echocardiographic appearance.', 15 We have also
observed this in patients with fresh thrombi in the left
ventricular cavity (figure 9). The short-term clinical
setting, together with the irregular motion pattern of
the bandlike structure, the marked curvilinear shape
with beat-to-beat variations, and the associated wall
FIGURE 9. Fresh thrornbus (Th) (arrows) in a patient with acute
myocardial infarction recognized in the apical views on the tenth hospital day. This finding was not present on two previous studies. Note the
echo-free space on both sides of the cavitary margin of the thrombus,
imparting the appearance of an aberrant band or trabeculation. For
further details, see text. Abbreviations as in previous figures.
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KEREN et al.
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motion abnormalities usually help in reaching the correct diagnosis of fresh thrombus.
Prominent right ventricular trabeculae were found to
obscure the right ventricular/septal border on M mode
echocardiography in this and previous studies. 16, 11 On
two-dimensional echocardiography the true septal border was usually easily identified. In cases with both
hypertrophic and fibrotic trabeculations, however,
many imaging planes were sometimes needed for recognition of the septal margin. Additionally, in some of
our patients with longitudinal left ventricular bands
aligned with the septum, the left septal border was
obscured on M mode echocardiography. These structures may lead to overestimation of the septal thickness
and erroneous M mode echocardiographic diagnosis of
asymmetric septal hypertrophy.
Our study demonstrated the reliability of two-dimensional echocardiography in recognizing left ventricular aberrant bands and hypertrophic or fibrotic left
ventricular trabeculations (table 1). Echocardiography
was also useful in recognizing these structures in the
right ventricular cavity but was inaccurate in discriminating among them.
The potential role of left ventricular aberrant bands
in the generation of transient systolic murmurs and/or
ventricular arrhythmias has not been clearly established.2's3, "I The accuracy of echocardiography in
recognizing left ventricular bands makes it suitable for
use in prospective studies to assess the clinical importance of these structures.
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CIRCULATION
Echocardiographic recognition and implications of ventricular hypertrophic
trabeculations and aberrant bands.
A Keren, M E Billingham and R L Popp
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Circulation. 1984;70:836-842
doi: 10.1161/01.CIR.70.5.836
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Copyright © 1984 American Heart Association, Inc. All rights reserved.
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