Download Lecture 18 Foreign Bodies, Masses, etc.

Lecture 18
Foreign bodies,
Masses, Etc.
Holdorf
Foreign Bodies
• Etiology
– Foreign bodies (missiles)
– Iatrogenic (healthcare provider induced
– Bullets
– Knives
– Nails
– Ice picks, etc.
• Pathophysiology
– Penetrating missiles may cause:
– Myocardial rupture
– ASD and or VSD
– Valvular disruption
– Pericardial effusion (25-50% will not have a effusion
– Coronary artery trauma
• Physical signs
– Bleeding (entrance and possible exit wound)
– Murmur possible
– Tamponade physiology
• ECHO
– Missiles may occur anywhere in the heart – look for echogenic structures
with strong reverberations
– Pericardial effusion not always present
– Disrupted valve leaflets/support apparatus
– ASD/VSDs may be visualized if large enough
– Look for wall motion abnormalities
– Always perform a micro-cavitation study to rule out an atrial level shunt
– NOTE:
– Use x-rays for reference. Use off-axis views
DOPPLER
• Intracardiac shunt may be present in the case of missile
penetration.
• Valvular regurgitation may be present
• ASD/VSDs may demonstrate abnormal or turbulent flow
• Trans-valvular respiratory flow variations when tamponade
physiology is present
• NOTE: What part of the heart is most likely to be affected by
cardiac contusion?
– Right ventricle
Bullet in the heart via CT scan
Bullet in the region of the tricuspid
valve
MASSES
• Etiology
– Thrombus formation
– Benign tumors (most common are myxomas)
– Malignant tumors
– Primary < 20%
– Metastatic (more common)
What might be the 1st indication of metastatic cardiac disease?
Pericardial effusion
Which cardiac chamber is most likely involved with metastatic tumors?
Right atrium
The most common benign tumor on the aortic valve is
papillary fibroelastoma
Myxoma
Metastatic tumor
Papillary fibroelastoma
Masses: Pathophysiology
• Thrombus may form in areas of Akinesis or dyskinesis
• Left atrial thrombi usually associated with MS and left atrial
enlargement
• Most commonly found at ventricular apex (anterior MI’s)
• Papillary fibroelastoma (10% of all primary cardiac tumors – 85% of
valve tumors- mostly on AoV and MV).
• Rhabdomyoma is most common benign tumor in children.
• Approximately 20% of primary cardiac tumors are malignant
• Metastatic (secondary) are more common than primary
• Most metastatic tumors are sarcoma, melanoma or lymphoma from
the breast or lung
• Physical Signs:
– Valvular stenosis and/or regurgitation may result in murmurs
• Echo
– Thrombus may be layered, pedunculated, multi-lobulated, or single.
– Thrombus will appear as an echogenic mass in areas of Akinesis or
dyskinesis
– Search ventricular apex closely with a high frequency transducer (5 MHzshort focus)
– To rule out artifacts, try to visualize the mass at different depths and from
two or more views
– Right sided masses can be delineated with micro-cavitation injections.
– Angiosarcoma seen most often in the RA: is the most common primary
tumor
Know how to identify a TEE image of a left atrial appendage clot.
Left atrial appendage
Doppler-Valvular stenosis and or regurgitation
may occur with obstructive masses.
Myxomas
• Etiology
– Benign tumors (comprise 30% of all primary benign cardiac tumors in adults)
• Pathophysiology
– Over 75% of myxomas are left atrial
– Atrial myxomas may mimic mitral stenosis
• Physical signs
– Malaise/dyspnea
– Chest pain (rare)
– Dyspnea
– Murmur of mitral stenosis with tumor plop is classic (50% of time)
– Embolic phenomena(35% of the time)
– Know that Myxoma symptoms mimic mitral stenosis
Echo
• Atrial myxomas usually attach to the interatrial septum
• Intra-cavity tumors will usually move with blood flow
• Intra-myocardial tumors usually have borders or texture which is
different from myocardium
DOPPLER
Stenosis and regurgitation may be present with obstructiuve left
atrial masses
Know that left atrial myxomas are usually attached to the
interatrial septum
Left atrial myxoma M-mode