Dr. Fuad Farooq

INFECTIVE ENDOCARDITIS AND HEART MASSES

Infective Endocarditis

IntroductionInfective endocarditis occurs primarily on cardiac

valves but can involve other endocardial surfaces or intracardiac devices

Potentially fatal with 6 month mortality rate of 25 to 30%

The incidence of IE is higher in patients who have valvular heart disease (rheumatic valve, bicuspid aortic valve, mitral valve prolapse, or prosthetic valve) or congenital heart disease and among intravenous drug users

Most commonly mitral and aortic valves are involved but involvement of right side of heart is not uncommon, especially in intravenous drug users

Hydraulic features of the blood stream are important in the pathogenesis of endocarditis

Associated with a high-pressure source (i.e., aorta, left ventricle) that drives blood at a high velocity through a narrow orifice (coarctation, PDA, VSD, AR or MR or obstructive hypertrophic cardiomyopathy) into a low-pressure chamber

Introduction

Rodbard S. Blood velocity and endocarditis. Circulation, 1963;27:18-28

Since the 1st M-Mode echo observation of valvular vegetation in 1973, the role of echo in diagnosing IE has grown in conjunction with improvement in resolution and technology including Doppler echocardiography, color flow imaging, and transesophageal echocardiography (TEE)

Indeed the echo detection of vegetation is one of the two major diagnostic criteria for IE

Introduction

American Heart Journal, 1973;86:698-704

Vegetation is an oscillating intracardiac mass on a valve or supporting structure or in the path of regurgitation get or an iatrogenic device

Can be linear, round, irregular or shaggy and frequently show high frequency flutter or oscillation

Echocardiographic Appearance

Echocardiographic Appearance

Other associated findings AbcessesNew partial dehiscence of prosthetic valveNew valvular regurgitation

Initial attachment to MV and TV is usually on atrial side

An aortic vegetation usually start from ventricular surface

Echocardiographic Appearance

The sensitivity of 2D echo for the detection of vegetation depends on the size and location of the vegetation and echocardiographic window used

The sensitivity for detection of vegetation with TTE is 65 to 80% when size of vegetation <1cm and with TEE is 95%

For prosthetic endocarditis the diagnostic yield of TTE is especially poor, but the sensitivity of TEE is 90%

Echocardiographic Appearance

Journal of the American College of Cardiology, 1989;14:631-38 Journal of the American College of Cardiology, 1991;18:391-97

The vegetation on the right side of the heart are larger (mean diameter 17mm) than those on the left side

Vegetations frequently persist after successful medical treatment, however persistent vegetation are not independently associated with the late complication

Echocardiographic Appearance

Complications arise from primarily from Vegetation embolizationDestruction of valve or intracardiac structuresAbcesses and subsequent haemodynamic

deteriorationIn the left sided valve endocarditis, the frequency of

clinical complications increased with the greater mobility and size of vegetation

When vegetations were larger than 11 mm, 50% or more of patients developed at least one complication of infective endocarditis

In patients with tricuspid valve endocarditis, PE is the most common complication 69%

Complications

StructuralCusp or leaflet rupture/flailPerforationAbscessAneurysmFistulaDehiscence of prosthetic

valvePericardial effusion (more

frequent with abscess)

EmbolizationSystemicCerebralPulmonary

Hemodynamic compromiseValvular regurgitationAcute mitral regurgitationAcute aortic regurgitationPremature mitral valve

closureRestrictive mitral inflow

patternValvular stenosisShuntCongestive heart failure

Complications

When the endocardial surface is traumatized, a series of events may lead to platelet deposition, creating a nonsterile platelet fibrin thrombus

Libmann sacks endocarditis: (Associated with APLA)This condition usually involve mitral valve and

is found most commonly on the basal portion of MV but it can extend to the cordal structure or papillary muscles

The lesions are difficult to see with TTE

Non-bacterial Thrombotic Endocarditis

Young maleIntravenous drug abuserPresented with fever, pedal edema and

shortness of breath

Case

Vegetation on Prosthesis

Vegetation on Shunts

A metastatic tumor also can involve cardiac valves and produce lesions similar to those in Libman-Sacks endocarditis. This is called marantic endocarditis and occurs most commonly with Hodgkin disease and adenocarcinoma of the lung, pancreas, stomach, and colon

Marantic Endocarditis

Several limitations and pitfallsOther lesions of the valves, such as marked

myxomatous degeneration of the mitral valve, nonbacterial thrombotic endocarditis or tumor, thrombus attached to the valve (i.e., papilloma), may simulate or mask vegetations

When a valve is sclerotic, calcified or prosthetic, it is more difficult to visualize a vegetation - TEE may be useful

Clinical presentation and lab data need to be incorporated into the interpretation of the echocardiographic findings

Clinical Caveats

TUMORS AND MASSES

Detection of a large intracardiac mass is an impressive experience for clinical echocardiographers

Some cardiac masses are suspected from the clinical presentation of the patient and other are incidental findings

Occasionally, a normal structure or a variant of a normal structure may appear as an intracardiac mass

Accurate diagnosis is crucial because misinterpretation may lead to an incorrect management strategy, including an unnecessary surgical procedure

Cardiac Masses

Cardiac masses can be classified as Cardiac tumorThrombusVegetationIatrogenic materialNormal variantExtracardiac structure

These masses usually can be differentiated by their size, shape, location, mobility and attachment site as well as by their clinical presentation

Cardiac Masses

Echo Indications in Cardiac Masses

Although primary cardiac tumors usually are benign, they can cause systemic symptoms, embolic events, malignant arrhythmias, chest pain, and heart failure

So, it is recommended that cardiac tumors be removed whenever possible

They can beBenignMalignant

Primary Secondary

Cardiac Tumor

Tumor and Masses

Tumor and Masses

Not all masses detected with echocardiography are thrombus or intracardiac tumor

The normal appearance of cardiac and extracardiac structures can be misinterpreted as an intracardiac mass

…Normal Anatomic Varients

…Normal Anatomic Varients

…Normal Anatomic Varients

Cordae

Lipomatous Interatrial Septum

Moderator Band

Moderator Band

Reverberation Artefact

Papillary Muscle

Pacemaker Lead

Chiari Network

Lamble’s

Myxoma is the most common cardiac tumor, accounting for 20 to 30% of intracardiac tumors

LA is the most common location with attachment site at the atrial septum

Typical M-mode and 2D echo appearanceOther locations and attachment sites have

been observed including RA, RV, LV and atrioventricular valve

Atypically located myxoma is usually familial - Carney Complex

Familial atrial myxomas account for 7% of all atrial myxomas

Myxoma

Atrial myxoma appear gelatinous and friable with occasional central necrosis

Embolic events are more common with a small myxoma

These tumors can obstruct AV valveYearly echo is indicated after resection of

myxoma at for 5 years

Myxoma

Fibromas usually are located in the LV free wall, ventricular septum or at the apex

It is well demarcated from surrounding myocardium by multiple calcifications

May grow in LV cavity and interfere with LV fillingPotential problems resulting from a fibroma are

congestive heart failure and malignant arrhythmias

When the tumor is located at the apex, the condition may be misinterpreted by other imaging modalities as apical hypertrophic cardiomyopathy

Cardiac Fibroma

It is the most common cardiac tumor in children, particularly those with tuberous sclerosis

Rhabdomyomas are often multiple, found in RV, RVOT and even in pulmonary artery

May be diagnosed before birth with fetal echo

Rhabdomyoma may regress spontaneously after birth

Cardiac Rhabdomyoma

It is a benign intracardiac tumor, found in the endocardium

These tumors are usually small (mean size 12 into 9 mm) and have characteristic stippled edge with shimmer or vibration at the tumor blood interface

Most frequently papillary fibroelastomas are located on the aortic valve (either aortic or ventricular surface), TV, PV, Septum, LV free wall, RVOT and LA

90% of patient have single tumor and other 10% have multiple tumors

Papillary Fibroelastoma

Primary cardiac pheochromocytomas is very rare but it has characteristic location, size and shape

Found mostly in AV grove, well circumscribed and ovoid, ranging from 1.5 to 5.1 cm

Common in female (mean age 38 years)Coronary angio shows that the tumor has

coronary neovascular blood supply

Pheochromacytoma

Malignant primary cardiac tumors include Angiosarcoma Rhabdomyosarcoma Myxosarcoma Osteosarcoma Fibrosarcoma Synovialsarcoma

Angiosarcoma occur commonly in RA in conjuction with paricardial effusion

Rhabdomyosarcoma and fibrosarcoma can occur any where in the heart

Synovial sarcoma is rare and occurs in RA

Malignant Tumors

Frequently secondary malignant tumors metastasize from lungs, breast, kidney, liver, melanoma, osteogenic sarcoma

Whenever RA mass is detected, the IVC should be scanned carefully

Secondary tumor

Secondary tumor

RA thrombus: Thrombi from lower extremity deep vein must

go through RA to pulmonary circulation They are mobile, have a characteristic popcorn

or snake like appearance Almost always are associated with pulmonary

embolism

Thrombus

RV thrombus

Thrombus

LA Thrombus: Common in mitral stenosis or atrial fibrillation Infrequently occurs as a paradoxical embolus from

an RA thrombus passing through a patent foramen ovale

TTE is limited in detecting thrombus in LAA In all patients, the LA appendage is visualized from a

transesophageal window

Thrombus

LV thrombus Easily differentiated from a tumor because the

thrombus is almost associated with akinetic to dyskinetic myocardium underlying the thrombus

Contrast echo can be very helpful in identifying and evaluating an apical mass/thrombus

Thrombus

IVC CLOT

Thrombus

caseYoung femaleWith chest pain

Another case

Take Home Message

Take Home Message

Take Home Message