ALSHARQIA ECHO CLUB Al Qusaibi HotelAl KhobarMay 23rd 2013Eric McWilliams MB, FRCPI, FRCP, FACCConsultant Cardiologist Dhahran Health CenterDiplomate of the Certification Board of Cardiovascular Computed Tomography 2008 2018Honorary Clinical Senior Lecturer, Brighton and Sussex Medical School August 2009 August 2014

History75 yr lady dyspnoea on exertionType 2 DiabetesHypertensionHypothyroidismHyperlipidemiaGlaucoma

No murmursChest clear

Echo

EchoMass 2.7 x 3.3 cmsPA pressure 43mmHg above RA

Transesophageal Echocardiography

3D RTE Left Atrial Surgeons ViewPhillips IE 33

What Is It ?Calcified Amorphous Tumour (CAT)Mitral Valve ThrombusCalcified Vegetation Pericardial TeratomaCaseous Calcification of Mitral Annulus Left Atrial SarcomaArtefact

CXR

Cardiac CT

CTA

CMR

No Enhancement with Gad

CTCMRWhat is it ?

What Is It ?Calcified Amorphous Tumour (CAT)Mitral Valve ThrombusCalcified Vegetation Pericardial TeratomaCaseous Calcification of Mitral Annulus Left Atrial SarcomaArtefact

Mitral Annular CalcificationCaseous CalcificationDegenerative abnormality 10% of >50yr olds commoner in womenDeposition of calcium between the basal infero-lateral ventricular wall and posterior mitral leafletTypically posterior mitral annulusSoft periannular calcification : calcium, fatty acids and cholesterolToothpaste like materialCaseous calcification of the mitral annulus

Caseous Calcificationof Mitral AnnulusRare0.6% of MAC patients in echo series2.7% necropsy seriesUsually incidental findingMitral stenosis can occurMisdiagnosed as abscess, cardiac tumour etcMAC and Caseous calcification similar baseline characteristics:Elderly, hypertension,coronary artery disease, aortic disease etc

Caseous Calcification

CATCalcified amorphous tumor (CAT) was coined in 1997 by Reynolds et al,1 who described 11 cases with non neoplastic cardiac masses characterized by a pedicle and diffuse calcification

Evaluation of Intra- and Extra-Cardiac Structures Cardiac CTCMREvaluation of cardiac mass (suspected tumor or thrombus) A (8) Patients with technically limited images from echocardiogram, MRI, or TEE Evaluation of pericardial conditionsEvaluation of cardiac mass (suspected tumor or thrombus) A (9)Use of contrast for perfusion and enhancement Evaluation of pericardial conditions (pericardial mass, constrictive pericarditis) A (8)Appropriateness Criteria ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR

Ghada Al Dossary, BS, RDCS Senior Echo TechnologistEric McWilliams MB, FRCPI,FRCP,FACCDhahran Health Center

Another Mitral Mass63 year old lady with chronic renal failureMultiple Access site failuresInfected Gortex graftMRSA bacteremiaWhat is the appropriate first imaging test ?

TTE

TEE

TTE or TEE ?Appropriateness CriteriaThe American College of Cardiology Foundation (ACCF)and the American Society of Echocardiography (ASE)

Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-ResistantStaphylococcus AureusInfections in Adults and Children 2011

Echocardiography is recommended for all adult patients with bacteremia. Transesophageal echocardiography (TEE) is preferred over transthoracic echocardiography (TTE).

Another Mitral Mass63 year old lady with chronic renal failureMultiple Access site failuresInfected Gortex graftMRSA bacteremia

TEE May 21st,2013

TEE May 21st,2013

What is It ?Caseous Calcification of Mitral AnnulusMitral Cusp ProlapseVegetationPapillary Fibroelastoma of Mitral ValveMitral Thrombus

What is it ?Mitral MassProlapse P2

MCP With Vegetations

Mitral Papillary Fibroelastoma

Staph Aureus Bacteremia 13% of hospital acquired Staphylococcus aureus infection develop endocarditis31% Staph aureus bacteremia : endocarditisEchocardiographyTEE

MRSA EndocarditisThe S. aureus organism carries particular adhesin molecules : can attack structurally Normal valves The bacteria can either internalise and persist locally, protected from antibiotic therapy and host defences, or lyse the endothelial cells, causing local tissue destruction and distant emboliS. aureus endocarditis can present either acutely or with a more indolent presentation

Acute pericarditis as presenting symptom of staphylococcal endocarditis: Mitral valve involvement with fistulous tract from LV to LA and subsequent pseudoaneurysm development. Eric McWilliams, Smriti Saraf, Katarzyna Dickinson World Journal of Cardiovascular Diseases, 2013, 3, 31-33 WJCD

Re-entry on Left Atrial Side

MRSA Endocarditis

TTE versus TEEThe sensitivity for detecting vegetation with 2D TTE is 65 to 80 percent and 95 percent with TEE but depends on vegetation size, location, and the echocardiographic windowThe yield of TTE is poor in patients with prosthetic valve endocarditis, but the sensitivity for TEE is 90 percent

TEE Mitral Bioprothesis

Vegetation on MVR

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