Fig. 3. When present, the Eustachian valve (arrow) can be well visualized in the right ventricular inflow view (see Chapter 3, Fig. 20). This patient's tricuspid valves were thickened and immobile owing to the carcinoid syndrome.
echobright and irregular, whereas fat usually appears as a less echodense, homogenous mass with smoother edges. Myxomatous mitral valves, when severely thickened, have been mistaken for tumors. Within the left atrial appendage, pectinate muscles appear as small multiple pyramidal structures with their bases continuous with the myocardial wall. Unlike masses and thrombi, the pectinate muscles are not independently mobile from appendage contractions. Small short linear echodensities known as "Lambl's excrescences" are often noted at the tips of the aortic valve leaflets, on both the left ventricular outflow tract and aortic side, as well as on the mitral apparatus in patients older than 50 yr old. Pathological studies have revealed these to be long fibrin strands, although the larger and more developed strands may contain cellular elements of papillary fibroelastoma.
Within the left ventricle, prominent left ventricle trabeculations, false tendons (Fig. 6), aberrant muscle bands or bridges, and subaortic membranes should be distinguished from tumors. Delineation of the origins and insertions of these structures, a cylindrical or linear morphology, and the presence of thickening during systole can aid in the differential diagnosis. Within the
right ventricle, the moderator band can appear quite thick, but its location extending from the apical free wall to the midseptum is characteristic.
An epicardial fat pad usually appears as a discrete "soft" or deformable mildly granular echogenic mass lying adjacent to pericardium, typically anterior to the right heart and/or adjacent to the atrioventricular groove. A useful clue for distinguishing pericardial fat is the identification of the echolucent cylindrical lumen of the coronary artery running within it. However, epicardial fat pads may be distributed anywhere around the heart. They tend to increase in size with age or in patients with longstanding steroid use.
Pleural effusions and ascites are occasionally confused with pericardial effusions. Proper identification should avoid the occasional misdiagnosis of echogenic collapsed lung segments, fibrin, or thrombus within the pleural or abdominal cavities, which can appear similar to tumor masses (Fig. 7).
Thrombi can form in the left atrial body and appendage, particularly in patients with atrial fibrillation, mitral stenosis, or hypercoagulable states (Fig. 8).
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