Transesophageal echocardiographic evaluation of left atrial mass lesions

Transesophageal echocardiography with color flow Doppler studies was performed on 12 consecutive patients who had left atrial mass identified by transthoracic echocardiography. In two patients with atrial myxoma, transesophageal study identified the tumor by its attachment to the atrial septum. In all instances, the tumors were larger and more mobile by transesophageal study and influenced the decision to operate early on an asymptomatic patient. In six instances the masses in the atria were deemed to be thrombi because of associated spontaneous echo contrast, location in the left atrial appendage, mitral valvular disease or prosthesis, atrial fibrillation, congestive heart failure, and enlarged left atrial chamber. In two patients the left atrial masses on transesophageal imaging were large vegetations attached to the mitral valve with ruptured chordae tendineae. In two patients, because of superior quality images obtained by transesophageal imaging, the atrial mass lesions were deemed to be a prominent muscle band between the left atrial appendage and left upper pulmonary vein. In conclusion, transesophageal echocardiography is superior to transthoracic imaging in elucidating the cause and significance of atrial mass lesions and helps in guiding appropriate therapy.     

Transesophageal echocardiography and cardiac masses

Although transthoracic two-dimensional echocardiography has been a procedure of choice for diagnosing cardiac mass lesions, the advent of transesophageal echocardiography (TEE) provided better visualization of cardiac structures, especially those at a considerable depth from the chest wall, and lesions that involve the left atrial appendage. In this study, we examined the experience at our institution with TEE imaging of cardiac mass lesions (excluding valvular vegetations) from April 1988 to July 1990. TEE studies detected 83 lesions (in 80 patients), which we characterized by type and site: 46 left atrial, 16 right atrial, 7 left ventricular, 2 right ventricular, and 12 extracardiac mass lesions. Of the 46 left atrial lesions, 9 were tumors and 37 were thrombi that involved the body of the left atrium, the left atrial appendage, or both. Associated mitral valve disease, chronic atrial fibrillation, or spontaneous microcavitations were common. Of the 16 right atrial mass lesions, 4 were tumors and 12 were thrombi, including "string" thrombi characteristic of venous thromboembolism. Of the seven left ventricular mass lesions, six were thrombi and one was a papilloma. Of the 12 extracardiac mass lesions, 2 were pericardial cysts and the rest were solid lesions. TEE added new or important clinical information beyond that derived from transthoracic echocardiography in left atrial thrombi, right atrial masses, and extracardiac lesions and was assessed to have influenced the management of patients most in these areas also. TEE is a useful addition to transthoracic echocardiography for diagnosis and clarification of cardiac mass lesions in selected patients.     

Transesophageal echocardiographic evaluation of right atrial mass lesions

Transesophageal echocardiography with color flow Doppler studies was performed on 10 consecutive patients who had right atrial masses identified by transthoracic echocardiography. In one patient with right atrial myxoma, transesophageal study identified the tumor by its attachment to the atrial septum and ruled out the transthoracic finding of possible additional tumor mass in the right ventricle. In two instances the mass in the atria were deemed to be thrombi because of lack of attachment to the atrial septum, atrial fibrillation, and enlarged right atrial chambers. In all patients, the thrombi appeared larger by transesophageal study and was associated in one instance with atrial septal defect. The atrial septal defect was not identified by the transthoracic study and probably accounted for stroke of the patient through paradoxical emboli. In six patients, because of superior quality images rendered by transesophageal imaging, the right atrial mass lesions were deemed to be anatomic variants, which included prominent eustachian valves, remnants of Chiari network, and thickened atrial septum. We concluded that transesophageal echocardiography is superior to transthoracic imaging in elucidating the cause and significance of right atrial mass lesions and that it helps in guiding appropriate therapy.     

Cardiac Masses on Cardiac CT: A Review

Cardiac masses are rare entities that can be broadly categorized as either neoplastic or non-neoplastic. Neoplastic masses include benign and malignant tumors. In the heart, metastatic tumors are more common than primary malignant tumors. Whether incidentally found or diagnosed as a result of patients’ symptoms, cardiac masses can be identified and further characterized by a range of cardiovascular imaging options. While echocardiography remains the first-line imaging modality, cardiac computed tomography (cardiac CT) has become an increasingly utilized modality for the assessment of cardiac masses, especially when other imaging modalities are non-diagnostic or contraindicated. With high isotropic spatial and temporal resolution, fast acquisition times, and multiplanar image reconstruction capabilities, cardiac CT offers an alternative to cardiovascular magnetic resonance imaging in many patients. Additionally, cardiac masses may be incidentally discovered during cardiac CT for other reasons, requiring imagers to understand the unique features of a diverse range of cardiac masses. Herein, we define the characteristic imaging features of commonly encountered and selected cardiac masses and define the role of cardiac CT among noninvasive imaging options.     

经胸超声心动图可用于无症状纵隔肿瘤的诊断

目的评价经胸超声心动图对纵隔肿瘤的诊断价值。方法回顾性分析2018年1月1日~2019年12月31日经胸超声心动图检查首次发现纵隔肿瘤的体检者临床资料,总结纵隔肿瘤在经胸超声心动图中的超声特点,并分别与放射影像（X线和CT扫描）及组织病理对比。结果共获得20例经胸超声心动图诊断纵隔肿瘤的无症状患者,检出纵隔肿瘤分为囊肿9例、胸腺肿瘤5例、淋巴结肿大3例、畸胎瘤2例、淋巴瘤1例。相较X线诊断而言,超声检查纵隔肿瘤有着较为明显的优势。此外,超声对纵隔肿瘤的检查价值也不亚于CT检查（Kappa=0.792,P＜0.001）。以病理检查结果为金标准,经胸超声心动图诊断纵隔肿瘤的误诊率为15%,对肿物良恶性质诊断的敏感性为75%,特异性为92%。结论经胸超声心动图检查可以用于纵隔肿瘤的诊断,不仅能对纵隔占位病变的内部结构进行观察,还可以对其良恶性质进行判定。      

Recurrent pulmonary embolism originating from right atrial myxoma.

The use of transesophageal echocardiography is a useful adjunct to transthoracic echocardiography in the diagnosis and management of right atrial tumors in patients who are thought to have idiopathic recurrent pulmonary embolism, especially with suboptimal transthoracic echocardiography studies. We describe a 30-year-old woman with a history of recurrent pulmonary embolism who was admitted for investigation of pleuritic chest pain in whom transesophageal echocardiography played a critical role in the diagnosis and management.     

声学造影评估心内占位性病变血流灌注状况的初步探讨

目的探讨心肌声学造影评估心腔内占位性病变血运状况的可能性。方法常规超声发现心腔内占位性病变后,经静脉行声学造影观察其灌注效果。结果共观察了2例患者心脏占位性病变灌注情况。其中：病例1为左心内占位性病变患者,经静脉注射声学造影剂后见该占位病变与心肌同步出现灌注显影。提示该病变血流丰富,术后病理证实为胚胎型横纹肌肉瘤。病例2为左心房内占位性病变患者,造影后未见该占位性病变显影。提示该病变为无血流病变,术后病理证实为血栓。结论声学造影方法可用于心内占位性病变血运状况的评估,对于判断病变的性质可能有一定的帮助。     

Transesophageal echocardiography in the evaluation of mediastinal masses.

To assess the diagnostic impact of transesophageal echocardiography in the evaluation of mediastinal masses, 30 patients with mediastinal abnormalities detected by routine chest roentgenogram underwent transthoracic and transesophageal echocardiography. Subsequently, 29 of the patients underwent computed tomography and 16 underwent magnetic resonance imaging. The location and structure of the masses as well as their relationship to the surrounding structures were assessed. Anatomic confirmation and histopathologic diagnosis of the mediastinal masses by surgical resection and biopsy was available for all patients. Transesophageal echocardiography was more accurate than transthoracic echocardiography in detecting mediastinal masses (90% versus 73%), in identifying their structure (100% versus 90%), and in evaluating their relationship to contiguous organs (89% versus 81%). No complication was observed during the examinations. Computed tomography correctly diagnosed the location, structure, and relationships in all patients but one; magnetic resonance imaging correctly evaluated the mediastinal masses in all 16 patients. Our study suggests that transesophageal echocardiography is a valuable and safe complementary method of evaluating mediastinal masses. Moreover, this technique allows the obstruction of vessels and heart cavities, valve regurgitation, and right and left ventricular function to be easily assessed.     

Evaluation of the aortic and mitral valves with cardiac computed tomography and cardiac magnetic resonance imaging

Cardiac computed tomography (CT) produces high-quality anatomical images of the cardiac valves and associated structures. Cardiac magnetic resonance imaging (MRI) provides images of valve morphology, and allows quantitative evaluation of valvular dysfunction and determination of the impact of valvular lesions on cardiovascular structures. Recent studies have demonstrated that cardiac CT and MRI are important adjuncts to echocardiography for the evaluation of aortic and mitral valvular heart diseases (VHDs). Radiologists should be aware of the technical aspects of cardiac CT and MRI that allow comprehensive assessment of aortic and mitral VHDs, as well as the typical imaging features of common and important aortic and mitral VHDs on cardiac CT and MRI.     

Intracardiac Echocardiography

Intracardiac echocardiography (ICE) uses a catheter‐based steerable ultrasound probe that is passed into the right heart chambers to image intracardiac structures. The transducer can be variably positioned for optimal imaging: in the inferior vena cava to visualize the abdominal aorta; in the right atrium for the interatrial septum, aortic, mitral, and tricuspid valves, and pulmonary veins; or in the right ventricle for the left ventricular function, outflow tract, or pulmonary artery. Intracardiac echocardiography is primarily used for imaging during an invasive cardiac procedure using conscious sedation, when transthoracic image quality would likely be inadequate, and transesophageal imaging would require general anesthesia. Intracardiac echocardiography is generally well tolerated and provides adequate images and sufficient information for the procedure performed. In the cardiac catheterization laboratory, ICE is routinely used for patent foramen ovale, atrial septal defect, and ventricular septal defect closures, allowing adequate percutaneous placement of septal occluders. It is now being considered in the current era of transcatheter aortic valve implantation necessitating improved imaging approaches for accurate placement. It is also routinely used for trans‐septal punctures during mitral valvuloplasty and, more recently, with the advent of left atrial appendage closure devices. This article provides a comprehensive review of the current technology for ICE and its growing applications in the realm of interventional cardiology.     

Comparison of transthoracic and transesophageal echocardiography in the diagnosis of intracardiac tumors in adults

To compare transthoracic and transesophageal echocardiography in the diagnosis of intracardiac tumors, 17 patients (8 men and 9 women, aged 19 years to 67 years) whose intracardiac tumors were detected by echocardiography were studied in a 4-year period. Of these, 14 patients underwent cardiac surgery and 13 were proved to have tumors. There were 4 false-positive and 2 false-negative diagnoses by transthoracic echocardiography, but only one false-positive and no false-negative diagnosis by transesophageal echocardiography. The stalk of a myxoma was detected clearly in 5 of 11 patients by transthoracic echocardiography, whereas in 10 of 11 it was detected by transesophageal echocardiography. The detailed morphologic characteristics of the tumor, such as contour of the tumor, and the presence of cysts and calcification in the tumor, were seen more clearly with transesophageal echocardiography than with transthoracic echocardiography. © 1994 John Wiley & Sons, Inc.     

Color Doppler sonographically guided transthoracic needle aspiration of lung and mediastinal masses.

OBJECTIVE: This study investigated the diagnostic value of color Doppler sonographically guided transthoracic needle aspiration in lung and mediastinal masses. METHODS: B-mode and colorDoppler sonographic images were obtained in 48 patients with mediastinal or peripheral pulmonary tumors. Color Doppler sonography was used to show the vascular structures before the transthoracic needle aspiration procedure. It was also used to locate the needle tip during the procedure by showing the twinkling sign. This maneuver was performed with motion of the inner stylet. Pathologic and microbiological examination of the aspirates was made. RESULTS: Vascular structures were detected in 37 cases on color Doppler images and in 10 cases on B-mode images. Similarly, the needle tip was observed in 39 cases on color Doppler images but in only 9 cases on B-mode images. No complications were observed except partial pneumothorax in 2 cases. The method had sensitivity of 90.0%, specificity of 87.5%, a positive predictive value of 97.2%, a negative predictive value of 63.6%, and diagnostic accuracy of 89.6%. CONCLUSIONS: Color Doppler sonographically guided transthoracic needle aspiration is a safe diagnostic method in malignant lung tumors, especially peripheral tumors, because of its ability to differentiate vascular structures within a tumor before the transthoracic needle aspiration procedure. It provides additional information about the location of the needle tip.     

胎儿心脏肿瘤的产前超声诊断

目的 探讨多普勒超声产前诊断胎儿心脏肿瘤的临床价值。方法 在胎儿心脏多切面观仔细观察房室腔和心包腔内有无肿块及检测肿块所致的血流梗阻和病理变化。结果 9例产前超声诊断为胎儿心脏肿瘤者,经尸体解剖和心脏手术证实8例诊断正确,1例假阳性。8例胎儿心脏肿瘤中位于左室4例,右室2例,心肌内1例,心包腔内1例。其中横纹肌瘤5例,纤维瘤2例,脂肪瘤1例。声像图特征为在心腔内可一个形态稳定、边界清晰、内部回声均匀的等回声或高回声肿块。结论 超声心动图是诊断胎儿心脏肿瘤的可靠方法,对于肿瘤定位、评估继发性病理改变具有重要价值。     

Doppler myocardial imaging: A new method of data acquisition for three-dimensional echocardiography

The precise morphologic characteristics of any intracardiac tumor have important implications regarding surgical planning and operative repair. Three-dimensional echocardiography has proved to be a valuable clinical technique in this field. Current methods of three-dimensional reconstruction of two-dimensional images are based on the standard gray-scale imaging technique. However, precordial gray-scale data-set information is frequently of suboptimal quality because of data degradation caused by ultrasound attenuation by chest wall structures. This has limited the use of the transthoracic three-dimensional technique to “echogenic” patients. Doppler myocardial imaging (DMI), a new ultrasound technique based on the Doppler principle, is influenced less by chest wall attenuation and in addition offers a better boundary detection algorithm for the cardiac structures. To determine if there may be a potential benefit of DMI to acquire data for three-dimensional reconstruction, a 33-year-old woman with a large intracardiac mass was studied. In this case three-dimensional gray-scale and DMI data sets were compared and contrasted with pathologic information. DMI allowed both the quantification of mass volume and the correct definition of the morphology of the mass. It was also possible to identify the precise site of attachment of the mass to the mitral valve leaflets. The information thus obtained was correlated with both operative and pathologic findings.     

Evaluation of cardiac masses by CMR—strengths and pitfalls: a tertiary center experience

Cardiovascular magnetic resonance (CMR) imaging is often considered the reference method to assess cardiac tumors. However, little data exists concerning the effectiveness of CMR for the accurate diagnosis of cardiac masses. We sought to understand the diagnostic value of CMR for evaluation of suspected cardiac mass. A total of 249 consecutive CMR cases performed at a single center from January 2005 to June 2013 for evaluation of masses found on echocardiography or computed tomography (CT) were included. All the clinical data and imaging features of these patients were retrospectively reviewed and medical records were verified for follow up care. More than half of the patients referred for evaluation of masses found at echocardiography or CT were found to have no evidence of mass by CMR. CMR correctly differentiated between thrombus and myxoma in 88.4 % cases. Malignant masses were accurately diagnosed on CMR. However, CMR missed or misdiagnosed a few cases of benign masses. Diagnosing cardiac masses remains an important use for imaging, despite technical difficulties with current imaging modalities. CMR can play a key role in confirming presence or absence of a mass. Additionally, in the presence of a mass, CMR can provide accurate differentiation of pseudomasses, benign and malignant masses. However, the limitations of CMR must be recognized.     

声学造影对心脏占位病变性质的鉴别诊断价值

目的对心脏占位病变患者进行心脏声学造影检查，评估心脏声学造影对心脏占位病变性质进行鉴别诊断的价值和准确性。 方法前瞻性选取2013年3月至2018年5月于华中科技大学同济医学院附属同济医院就诊且超声心动图检查发现心脏占位性病变的患者66例，对其进行传统二维超声心动图检查和心脏声学造影成像。应用目测法观察造影图像上病灶和邻近心肌的增强程度，病灶内无增强者判断为血栓，病灶内呈部分增强但增强程度低于邻近心肌者判断为良性肿瘤，病灶内呈明显增强、其增强程度接近或高于邻近心肌者判断为恶性肿瘤。同时对造影图像进行时间-信号强度曲线定量分析，计算病灶和邻近心肌造影剂峰值强度的差值ΔA，并采用ROC曲线分析法计算ΔA鉴别诊断不同性质占位病变的敏感度、特异度和准确性。所有心脏占位病变的性质均经"金标准"方法确诊。 结果经"金标准"方法确诊，66例患者中15例为血栓、23例为良性肿瘤、28例为恶性肿瘤。心脏声学造影目测法鉴别心脏内血栓的敏感度、特异度和准确性分别为100%、100%、100%，鉴别良性肿瘤的敏感度、特异度和准确性分别为91%、100%、97%，鉴别恶性肿瘤的敏感度、特异度和准确性分别为100%、95%、97%。心脏声学造影定量分析法所测得的ΔA鉴别血栓与心脏肿瘤的ROC曲线下面积为0.978，截断值-3.21 dB时，其敏感度、特异度和准确性分别为93%、100%、95%；鉴别恶性肿瘤与血栓、良性肿瘤的ROC曲线下面积为0.997，截断值0.45 dB时，其敏感度、特异度和准确性分别为100%、97%、98%。 结论心脏声学造影通过反映心脏占位病变的血供特点，能够对血栓、良性肿瘤和恶性肿瘤进行鉴别，无论心脏声学造影目测法，还是定量分析法对于鉴别心脏占位病变的性质均具有较高的诊断价值。     

急诊床旁经胸超声心动图诊断自发性心包填塞

目的探讨急诊床旁经胸超声心动图诊断自发性心包填塞的价值。方法自2000年1月至2005年8月,对本心脏中心24例经临床证实的心包填塞患者进行急诊床旁经胸超声心动图检查。结果急诊床旁经胸超声心动图正确检出24例心包填塞,无假阴性,敏感性100%,1例假阳性,特异性96%。其中恶性肿瘤侵犯心包7例,结核6例,急性夹层破裂5例,急性心肌梗死4例,白血病1例,甲状腺功能减低1例。结论急诊床旁经胸超声心动图能以床旁方式快速、安全、准确诊断心包填塞,为治疗决策提供重要的诊断信息。     

Harmonic imaging with Levovist for transthoracic echocardiographic reconstruction of left ventricle in patients with post-ischemic left ventricular dysfunction and suboptimal acoustic windows.

BACKGROUND: Attempts to perform transthoracic 3-dimensional echocardiography (3DE) are often encumbered by poor definition of chamber borders in adult patients who have technically suboptimal acoustic windows. METHODS: To assess whether harmonic imaging (HI) and contrast agents can facilitate transthoracic 3DE assessment of the left ventricle, we used fundamental imaging (FI), HI alone, and HI coupled with the echo-enhancing contrast agent Levovist in 15 consecutive patients with post-ischemic left ventricular (LV) dysfunction and technically difficult windows. Dynamic 3DE image data sets were obtained at 5-degree angles (36 slices) from a transthoracic apical view. From these data a total of 240 myocardial segments were analyzed with the use of dynamic short-axis paraplane slices at basal, middle, and apical LV levels (standard 16 segment model). For border definition, each segment was scored in random sequence on the following scale by 2 independent investigators: 0 = not seen, 1 = suboptimal visualization, and 2 = well defined. RESULTS: Our results showed a significant increase in the number of well-visualized segments when harmonic mode combined with Levovist injection was compared with FI and HI alone. CONCLUSION: Harmonic imaging alone improves LV assessment by 3DE when compared with FI. Contrast imaging in which Levovist is added to HI further improves the capability of transthoracic tomographic 3DE in the visualization of LV myocardial segments. This could allow 3DE by transthoracic windows to be used more widely in adults for the evaluation of LV volume and function.     

心脏黏液瘤多模态成像特点及诊断模式

目的 探究心脏黏液瘤(CM)多模态成像特点及其多模态诊断模式.方法 回顾性研究2016年7月至2019年8月在阜外医院行二维经胸超声心动图检查初诊为CM的178例患者,以病理结果为金标准,将研究对象分为CM组和非CM组,根据超声心动图特点将CM组划分为典型CM组和非典型CM组.分析归纳各组患者的临床特征,二维经胸超声心...     

Elusive left ventricular thrombus: Diagnostic role of cardiac magnetic resonance imaging-A case report and review of the literature

Identification of left ventricular mural thrombus (LVT) may be challenging depending on the imaging modality used. We present a case of LVT which was incidentally identified on cine cardiac magnetic resonance imaging (CMR). A sixty-four years old female presented with worsening dyspnea on exertion with troponin elevation. Transthoracic echocardiography (TTE) revealed a dilated left ventricle (LV) and ejection fraction (EF 30%) with thinning and akinesis of inferior/inferolateral wall was noted with basal and mid inferior wall aneurysm, and thrombus was not identified. CMR done to ascertain viability of myocardium revealed a mural thrombus within basal inferior aneurysm. This was not visualized on transthoracic echocardiography with and without use of contrast. She underwent coronary artery bypass grafting, bioprosthetic mitral valve replacement, resection and plication of posterior left ventricular aneurysm with removal of mural thrombus, and was started on anticoagulation with warfarin post-operatively for the apical thrombi. Cardiac magnetic resonance is a well suited imaging modality in detecting LVT due to its high resolution images and is more reproducible than TTE. In our patient, conventional TTE despite administration of echo-contrast agents failed to diagnose the presence of LVT in the basal inferior aneurysm as well as the apical thrombi. Delayed-enhancement CMR provides the greatest sensitivity for detection of left ventricular thrombus, superior to standard transthoracic and contrast-enhanced transthoracic echocardiography.