Case Presentation

A 32-yr-old female presented with a 1-mo history of fatigue, intermittent fevers, and dyspnea on exertion. One day before her doctor's appointment, she noted transient monocular blindness that resolved within 1 h. On physical exam, she had both a holosystolic apical and late diastolic positional rumble, diminished S1, and an end-diastolic "plopping" sound heard in late systole. She was sent for an echocardiogram to rule out cardiac source of embolus (Fig. 1; please see companion DVD for corresponding video). She subsequently underwent cardiac surgery and a left atrial tumor was excised and confirmed to be a myxoma on pathological examination.

DIFFERENTIAL DIAGNOSIS OF A MASS: NON-NEOPLASTIC STRUCTURES

Masses in or around the heart are most often incidental findings on echocardiography. Less frequently, a tumor involving the heart causes direct symptoms that lead the clinician to suspect a cardiac abnormality.

True intracardiac or extracardiac masses need to be distinguished from the entities in the following section.

Normal Structures/Variants Simulating Tumors

Intracardiac

In the right atrium, the Eustachian valve (also known as the valve of the inferior vena cava [IVC]) is a ridge of tissue that extends from the entry of the IVC to the interatrial septum. In fetal life, this valve directs blood

From: Contemporary Cardiology: Essential Echocardiography: A Practical Handbook With DVD Edited by: S. D. Solomon © Humana Press, Totowa, NJ

Eustachian Valve Echo

Fig. 1. This large atrial myxoma caused functional mitral stenosis and constitutional symptoms. They are usually solitary, mobile masses that are heterogenously hyperechoic. They arise most commonly from the interatrial septum and have a predilection for the left atrium. (Please see companion DVD for corresponding video.)

Fig. 1. This large atrial myxoma caused functional mitral stenosis and constitutional symptoms. They are usually solitary, mobile masses that are heterogenously hyperechoic. They arise most commonly from the interatrial septum and have a predilection for the left atrium. (Please see companion DVD for corresponding video.)

liver.-

liver.-

Eustachian Valve Echo

Subcostal View

Fig. 2. Subcostal images showing Eustachian valve (left, arrow) with directed flow on color Doppler examination (right). (Please see companion DVD for corresponding video.)

Subcostal View

Fig. 2. Subcostal images showing Eustachian valve (left, arrow) with directed flow on color Doppler examination (right). (Please see companion DVD for corresponding video.)

to the fossa ovalis. It can remain prominent in adults, where it appears as a transverse linear echo running approximately parallel to the tricuspid annulus across the posterior right atrium in right ventricular inflow views, or in subcostal views (Figs. 2 and 3; please see companion DVD for corresponding video for Fig. 2). The Chiari network is similarly an embryonic remnant of the sinus venosus, which extends from and is continuous with the Eustachian valve. It persists in 2-3% of normal adults (confirmed by autopsy), and appears on ultrasound as a lacy weblike or fenestrated membranous echogenic mass with a characteristic chaotic, undulating motion independent from that of the tricuspid valve and right heart (Fig. 4). On parasternal long- or short-axis views, bulging of the interatrial septum into the right atrium, owing to an interatrial septal aneurysm or left atrial volume overload, can be mistaken for a "tumor" when the scanning plane cuts tangentially across the septum. Careful inspection of both atria from all windows should clarify this misdiagnosis.

Annular calcification, particularly of the mitral apparatus, and fat deposition, often seen around the tricus-pid annulus and interatrial septum (interatrial septal lipomatous hypertrophy, Fig. 5; please see companion DVD for corresponding video), can also simulate intracardiac masses. Calcific deposits tend to be very

Diastole

Your Heart and Nutrition

Your Heart and Nutrition

Prevention is better than a cure. Learn how to cherish your heart by taking the necessary means to keep it pumping healthily and steadily through your life.

Get My Free Ebook


Post a comment