Giant right atrium in a foetus

Giant right atrium is a rarely reported condition, especially in intrauterine life. It may be mistaken with pericardial effusion and Ebstein's anomaly, which are more common causes of right atrial enlargement.We present a case of prenatal diagnosis of giant right atrium detected at 29 weeks of gestation by fetal echocardiography.     

Usefulness of nuclear magnetic resonance imaging for evaluation of pericardial effusions, and comparison with two-dimensional echocardiography

Nuclear magnetic resonance (NMR) imaging clearly delineates cardiovascular structures without interference from overlying bone and lung tissue. The techniques of NMR imaging and echocardiography were compared in 26 patients with pericardial effusions, 10 of whom had associated pleural effusions. In those patients with fluid detected by both techniques, estimated size of the effusion tended to be somewhat larger by NMR. NMR imaging detected several small pericardial effusions that were not visualized by echocardiography. Both techniques demonstrated loculation well, although NMR imaging was better for detecting fluid located superiorly at the aortic pericardial reflection site, medially at the border of the right atrium and posteriorly at the left ventricular apex. In the 14 patients with documented exudative effusions (10 pericardial, 4 pleural) NMR signals of varying intensity were present in the effusion. One patient had a documented transudative effusion and no NMR signal was observed in the fluid. NMR imaging clearly distinguished pericardial from pleural effusions. NMR imaging is indicated when a suspected pericardial effusions is not detected by echocardiography or when specific localization or fluid characterization is desired.     

Isolated Left Ventricular Diastolic Collapse in Pericardial Tamponade: An Uncommon Echocardiographic Finding

A case of circumferential moderate pericardial effusion causing isolated collapse of left ventricular cavity on two‐dimensional echocardiography is reported. Pericardial effusion, mostly of infective etiology, is relatively common in this part of the world. When large enough to cause tamponade, collapse of right atrium, right ventricle, and uncommonly left atrium can be seen. Left ventricular collapse is rare, both due to the larger muscle mass and higher chamber pressure.     

Diagnosis of a cardiac mass--a case report]

The authors describe a case of a recidivant pericardial effusion associated to a mass with an unusual, filamentous aspect that involved the upper part of right atrium and surrounded the upper vena cava. Despite the diagnostic techniques employed--transesophageal echocardiography and magnetic resonance imaging, the etiologic diagnosis could not be done, so a biopsy of the mass was made by percutaneous approach using transesophageal echocardiography to control the procedure. The histopathological result was an angiosarcoma of the right atrium. The authors make a brief review of the literature about this rare condition.     

Right atrium mass in a 28-year-old patient with pulmonary embolism taking contraceptives

We report the case of a 28-year-old woman taking contraceptives diagnosed with pulmonary embolism with a mass in the right atrium demonstrated by trans-thoracic echocardiogram that was not recognized on a previous angio-CT. Initially, it was thought to be a thrombus, but trans-oesophageal echocardiography and cardiac MRI showed data suggestive of cardiac neoplasm. Pericardial effusion and adjacent myocardial wall thickening noted on trans-oesophageal echocardiography were reported as signs that supported the possibility of malignancy, although cardiac MRI did not show wall infiltration signs. On the contrary, it demonstrated enhancement, which excludes the thrombotic nature of the mass and supports the diagnosis of neoplasm. The patient underwent surgery and biopsy proved that the mass was a myxoma. While myxomas are the most common among primary cardiac tumors, its attachment to the atrium free wall, far from the inter-atrium septum, the bi-lobed shape and accompanying pericardial effusion were atypical.     

Right atrial compression in postoperative cardiac patients: detection by transesophageal echocardiography

Four patients developed hypotension after heart surgery. Hemodynamic measurements revealed elevated right atrial pressure with normal pulmonary capillary wedge pressure. Conventional transthoracic two-dimensional echocardiography was technically suboptimal for detection of pericardial effusion. In each patient transesophageal echocardiography demonstrated significant compression of the right atrium by a localized mass. At reoperation atrial compression by an organized hematoma was found and in each instance successfully drained. Thus, transesophageal echocardiography is superior to transthoracic echocardiography in evaluating critically ill postoperative hypotensive patients and can differentiate isolated right atrial tamponade from other causes of hemodynamic deterioration such as prosthetic valve dysfunction or left ventricular systolic dysfunction, or both.     

Intracardiac echocardiography during simulated aortic and mitral balloon valvuloplasty: in vivo experimental studies.

The feasibility of intracardiac echocardiography with a low-frequency transducer to assess catheter position and detect complications during experimental aortic and mitral balloon valvuloplasty was studied in 10 dogs. Intracardiac echocardiography was performed with a transesophageal echocardiographic probe placed in the right atrium. In all instances high-quality images of cardiac structures were obtained. The guide wire and balloon catheter were clearly seen as they crossed the valves. With inflation the balloon was seen as a hyperechoic structure. Doppler echocardiography documented aortic regurgitation after inflations. Acute pericardial effusion was instantly detected. It is concluded that intracardiac echocardiography is a potentially useful technique for cardiac imaging, assessing wire and balloon catheter position, evaluating valvular regurgitation, and instantly detecting acute pericardial effusion. Further research in humans with low-frequency, catheter-based transducers needs to be performed.     

Primary cardiac sarcoma: two case reports

Two case reports of primary cardiac sarcoma, which is uncommon, are presented. The first case, a 38-year-old male, complained of chest tightness. Chest roentgenograms showed enlargement of the cardiac shadow and left pleural effusion. Transthoracic echocardiography and chest magnetic resonance imaging showed a tumor in the right atrium, and pericardial effusion. The tumor involved the right atrial wall and interatrial septum, and was partially resected. Pathohistological examination revealed angiosarcoma. He died 1 month later. The second case, a 19-year-old male complained of dyspnea and orthopnea. Chest roentgenograms showed pulmonary congestion. Transthoracic echocardiography showed a large mobile mass in the left atrium. An emergency operation was performed and the tumor was totally resected. Pathohistological examination demonstrated leiomyosarcoma. The postoperative course was uneventful, but the tumor rapidly recurred. Second and third operations were performed at intervals of 2 months. After the third operation, he was treated with radiotherapy. Local recurrence was not found but multiple distant metastases were found 2 months after completion of radiation therapy.     

Cardiac lymphoma associated with superior vena caval syndrome and cardiac tamponade: case history

A sixty-three-year-old patient with malignant histiocytic lymphoma of the heart presented with both superior vena cava syndrome and cardiac tamponade. A two-dimensional echocardiogram showed a large tumor mass in the right atrium and pericardial effusion with right ventricular compression. Superior and inferior vena cavagrams disclosed a lobulated tumor located in the right atrium that extended into and obstructed the superior vena cava. After the pericardial effusion was drained and the diagnosis was established, the patient was irradiated and given chemotherapy with resolution of the tamponade and superior vena cava obstruction.     

Follow-up of familial idiopathic dilatation of the right atrium

In 1979 the diagnosis of idiopathic enlargment of the right atrium had been made in four members of a family, living in the northeastern part of Switzerland. A 5-year follow-up study of these four patients by ECG, chest X-ray, bicycle-ergometry and echocardiography showed a variable evolution: One of the two patients with the originally largest atria, showed further massive enlargement of the right atrium, combined with tricuspid insufficiency. One presented unchanged echo findings. In the other two patients with originally smaller atria a discrepancy of the course was also observed: in one right atrial size increased considerably (with appearance of atrial flutter), in the other patient the size of the atrium remained unchanged. In both patients a pericardial effusion occurred. Subjective symptoms and physical working capacity did not change in the four patients.     

Primary angiosarcoma of the right atrium detected by magnetic resonance imaging.

A 20-year-old woman with a primary angiosarcoma of the right atrium is reported. The patient had a cardiorespiratory arrest due to cardiac tamponade with bloody pericardial effusion. Magnetic resonance imaging (MRI) revealed a tumor, which was corroborated by selective coronary angiography. Open-heart surgery was performed. The tumor relapsed however, and she died four months after operation. The tumor was undetectable by echocardiography, but MRI demonstrated a heterogeneous mass with focal areas of high- and low-signal intensity in the right atrium, suggesting that MRI may allow characterization of cardiac tumors.     

Life-threatening left atrial wall hematoma secondary to a pulmonary vein laceration: an unusual complication of catheter ablation for atrial fibrillation

Background: Several complications may occur during catheter ablation for atrial fibrillation (AF). We report an unusual case of left atrial wall hematoma without pericardial effusion secondary to a right inferior pulmonary vein (PV) laceration. The use of real-time transesophageal echocardiography (TEE) during the procedure can be useful for early detection of this potentially lethal complication.
Case report: A 49-year-old woman was referred for AF ablation. Her past medical history included severe systemic lupus with chronic renal failure treated with immunosuppressive and steroid drugs. A TEE-guided hybrid approach for AF ablation was performed with circular PV lesions and antrum and ostial electrical isolation. While performing the mitral isthmus line, the TEE showed a growing hematoma at the posterior left atrial wall. Rapidly, left atrium (LA) collapse associated with hemodynamic compromise occurred without any pericardial effusion. The patient was brought to the operating room. No pericardial effusion was seen at the time of surgery. The cardiac exploration showed a right inferior PV laceration. The visual inspection of the LA revealed thin and friable tissue. The patient survived. After 25 months of follow-up, she is still free from symptomatic AF.
Conclusions: Left atrial wall hematoma without pericardial effusion is a rare and life-threatening complication after catheter-based AF ablation. TEE is a valuable monitoring tool to accurately diagnose several acute complications and prompt rapid intervention.     

Hemorrhagic nonspecific pericardial effusion as an initial symptom of angiosarcoma of the right heart

HISTORY: A 45-year old woman presented at our hospital with intermittent fever in the last three weeks and progressive exertional dyspnea. In addition she suffered from physical asthenia. Seven months ago the patient was treated for symptomatic pericardial effusion in our clinic. INVESTIGATIONS: Physical examination revealed a pale skin color, epigastric pain on palpation and intense exertional dyspnea. Laboratory tests indicated microcytic anemia and high levels of LDH and CRP. The diagnosis of a large tumor of the right atrium and ventricle was based on the transthoracic echocardiogram and thoracic CT scan. The extent of the right atrial and ventricular mass of 9 x 8 cm was detected by trans-esophageal echocardiography. The thoracic and abdominal CT scan showed multiple nodular infiltrates in the basal lung fields and a cystic tumorous mass in the liver. DIAGNOSIS: The tumor developed in the short time of 7 months. Half a year ago, the transthoracic echocardiographic exam showed pericardial effusion with normal cardiac size, normal left ventricular function and no evidence of right ventricular outflow obstruction. No cardiac masses were observed. At that time pericardiocentesis was performed, but the pericardial fluid was cytologically negative for tumor cells.The diagnosis of angiosarcoma was made after surgical excision of the tumor and histological examination. There was only the possibility of a palliative therapy, because of the existence of pulmonary and liver metastases. CONCLUSIONS: Primary malignant cardiac tumors are rare and their prognosis is very poor. The heart angiosarcoma is often disseminated into the lungs and the liver at the time of clinical presentation. This case indicates that hemorrhagic nonspecific pericardial effusion, negative for tumor cells, can appear any time before a heart angiosarcoma is detectable by echocardiography.     

A serial echocardiographic study of myocardial abscess in a patient surviving staphylococcal septicemia

2D echocardiography was performed on a 4-year-old child suffering from right thigh abscess due to MRSA infection following diagnosis of pericardial effusion by USG abdomen. It revealed myocardial abscess and pericardial effusion. This child underwent series of 2D echocardiographic studies which showed image appearance of myocardial abscess with its time course of healing.     

Prolapsed left atrium behind the left ventricular posterior wall: Two dimensional echocardiographic and angiographlc features

Left atrial enlargement can usually be detected accurately using M mode echocardiography. However, in the presence of heart disease, asymmetric enlargement may lead to inaccurate assessment of left atrial size and shape. Pericardial effusion can usually be diagnosed on the basis of characteristic M mode echocardiographic findings. However, false positive patterns sometimes occur with the use of this single dimensional technique. Three patients with a greatly enlarged left atrium are described whose M mode echocardiogram suggested significant posterior pericardial fluid accumulation. In each patient, two dimensional echocardiography detected portions of a huge left atrium that prolapsed behind the left ventricular posterior wall and mimicked an isolated posterior pericardial effusion. In one case a right anterior oblique left ventricular cineangiogram suggested the presence of a ventricular septal defect or a false aneurysm of the left ventricle due to the prolapsed left atrium. Because two dimensional echocardiography can provide accurate spatial orientation with visualization of intracardiac structures in relation to one another in real time, it can identify the presence of left atrial prolapse and play an important role in the differential diagnosis of isolated echo-free spaces behind the left ventricle detected with M mode echocardiography.     

Comparison of Doppler and two-dimensional echocardiography for assessment of pericardial effusion.

Respiratory changes in left ventricular inflow velocities by Doppler echocardiography have been used to assess cardiac tamponade; however, Doppler echocardiography has not been compared to right atrial or right ventricular collapse. Pulsed Doppler echocardiography of left ventricular inflow velocities was performed with respiratory monitoring in 28 patients with small to large pericardial effusions. Ten of the 17 patients (59%) with large effusions had equalization of right-sided diastolic pressures before pericardial drainage. The measurements performed included percent change in left ventricular inflow peak early velocity, isovolumic relaxation time, change in inferior vena cava diameter from apnea to inspiration, and the presence of right atrial and right ventricular collapse. Percent change in early left ventricular inflow velocities significantly correlated with pericardial effusion size (p = 0.001) and right ventricular collapse (p = 0.007), and showed a trend with right atrial collapse (p = 0.10). Pericardial effusions with a left ventricular inflow velocity change > 22% were found to have right-sided equalization at a 95% confidence interval. Our data indicate that the respiratory changes in Doppler echocardiographic parameters are useful in the assessment of pericardial effusion and tamponade. This study concurs with the hypothesis that there is a continuum of hemodynamic compromise in pericardial effusion that is easily detected by Doppler echocardiography.     

Pericardiocentesis guided by two-dimensional contrast echocardiography

The clinical application of two-dimensional contrast echocardiography to pericardiocentesis was investigated in 20 patients with pericardial effusion. Multiple views were obtained to determine the ideal needle entry route. During pericardiocentesis, after 5 to 10 mL of pericardial fluid was withdrawn, 3 to 5 mL of agitated saline solution was injected through the exploring needle into the pericardium and a cloud of echoes indicated the needle's position. Contrast echoes were observed in all 20 patients. The procedure was performed smoothly in all patients except two (10%): the exploring needle was inserted into the right atrium in one patient and into the right ventricle in the other patient. The former promptly underwent a surgical drainage procedure, and the latter a second pericardiocentesis successfully guided by contrast echocardiography. The pericardial fluid was simply, safely, and successfully aspirated in the other 18 patients. We conclude that two-dimensional contrast echocardiography is valuable for locating needle position, thus facilitating successful pericardiocentesis in clinical practice.     

A case of chronic pancreatitis complicated by massive pericardial and right pleural effusion

A 42-year-old man was admitted complaining of dyspnea. Chest X-ray showed an increase in cardiac size, and echocardiography revealed a large volume of pericardial effusion. Pancreatic enzyme levels were elevated in both serum and pericardial effusion. Computed tomography and endoscopic retrograde pancreatography demonstrated a fistula connecting a pancreatic pseudocyst with the pericardium and the right pleural cavity. Massive pericardial and right pleural effusion is an extremely rare complication of chronic pancreatitis. In this case, computed tomography and endoscopic retrograde pancreatography were useful for diagnosing the fistula.     

Chronic intractable pericardial effusion associated with pulmonary hypertension: report of two cases

We report two cases of chronic intractable pericardial effusion associated with pulmonary hypertension. Case 1. A 35-year-old women was admitted to our hospital because of dyspnea and edema. Chest X-ray examination showed enlargement of cardiac, and pulmonary artery shadow. An electrocardiogram with high voltage of R in V1 and deep S in V5 suggested right ventricular hypertrophy. Pericardial echo-free space with dilated right ventricle was demonstrated by echocardiography. Cardiac catheterization revealed an elevated pulmonary systolic pressure of 120 mmHg. No intracardiac shunt was calculated. A diagnosis of primary pulmonary hypertension was made. Pericardial drainage diminished pericardial effusion. Soon after discharge, however, pericardial effusion increased and the patient died. Case 2. A 65-year-old man was admitted because of dyspnea. The findings of chest X-ray and echocardiography were essentially the same as Case 1. Pericardial effusion disappeared after pericardiocentesis, but appeared again one month later. Cardiac catheterization demonstrated an elevated pulmonary systolic pressure of 73 mmHg. Pulmonary-capillary-wedge pressure was normal. Pulmonary arteriogram showed occlusion of the pulmonary artery trees. A diagnosis of chronic thromboembolic pulmonary hypertension was made. Although diuretics and vasodilators decreased pulmonary-artery pressure, pericardial effusion was unchanged. We compared these two cases with 11 control patients of pulmonary hypertension without pericardial effusion. Venous pressure was higher than that in the controls in Case 1, but not different in Case 2. Thus, venous pressure did not fully account for pericardial effusion. In summary, chronic pulmonary hypertension should be added to the list of conditions known to cause pericardial effusion. In these cases, echocardiography revealed important signs, and cardiac catheterization was essential for definite diagnosis. Pericardial effusion associated with pulmonary hypertension was refractory to diuretics and vasodilators.     

A case of effusive-constrictive epicarditis found by electrocardiogram at a school health examination

An effusive-constrictive pericarditis confined to the epicardium is extremely rare in childhood. We report case of a 7-year-old boy with such a condition. During an annual school health examination, he was found to have low voltage activities on electrocardiogram. On admission, physical examination showed markedly distended abdomen due to ascites and hepatomegaly. Two-dimensional echocardiography revealed small ventricular cavities, extremely dilated inferior vena-cava, and a moderate amount of pericardial fluids. Pericardial and epicardial thickening were also suspected. Retrospectively, epicardial thickening was suspected on computed tomogram as well. Cardiac catheterization showed a typical diastolic dip and plateau pattern on the right ventricular pressure tracing, and deep x and y descents on that of the right atrium, suggesting that not pericardial effusion, but pericardial thickening mainly contributed to the cardiac dysfunction. Pericardiocentesis did not improve the clinical symptoms and high central venous pressure. On thoracotomy, we unexpectedly found intact pericardium and fibrotic epicardium covering the whole heart, so epicardiectomy was performed. Despite the fact that most of the fibrotic epicardium was removed, there were no immediate responses such as decrease in central venous pressure within the first 5 days after the surgery. Furthermore, it was not until two months later that all symptoms and hemodynamic parameters returned to normal levels. There have been several case reports of isolated epicardial constriction associated with pericardial effusion in English literature. However, we are unaware of such a report n Japanese. We concluded that it is important to evaluate the hemodynamics before and after pericardiocentesis, and to detect peri-and/or epicardial thickening by serial echocardiography and CT scan.(ABSTRACT TRUNCATED AT 250 WORDS)